Douglas Liou

All Publications

• Complications of Outpatient Chest Tube Management for Prolonged Air Leaks After Pulmonary Surgery. Annals of surgical oncology Randle, R. J., Bhandari, P., He, H., Berry, M. F., Backhus, L. M., Lui, N. S., Liou, D. Z., Shrager, J. B. 2024

  Abstract

  Air leaks are common after pulmonary surgery. Prolonged air leaks (PALs) may persist through discharge and often are managed with one-way valve devices (OWD). We sought to determine the course and complications of patients discharged with OWDs, risk factors for complications, and to evaluate the utility of clamp trials before chest tube (CT) removal.Single-institution, retrospective review of patients discharged with a OWD after pulmonary surgery between 2008 and 2022. Charts were examined for the presence of complications and CT duration. Differences in CT duration were compared by using the Wilcoxon rank-sum test.Sixty-four of 1917 (3.3%) pulmonary surgeries resulted in OWD use. Twelve of 64 (19%) patients discharged with a OWD suffered a complication. Nine of 64 (14%) had a CT-related readmission, and seven of 64 (11%) required PAL intervention. Patients sustaining a complication demonstrated longer CT durations before complication compared with duration in patients without complications, with median days of 13 [IQR 6-21] vs. 7 [IQR 6-12], p = 0.04). Five (7.8%) OWD patients developed an empyema; only one (20%) occurred before a CT duration of 14 days. Sixteen of 64 (25%) patients underwent a clamp trial before CT removal. One of ten (10%) failed even with no air leak present, whereas one of six (17%) failed with a present/questionable air leak.One-way valve device use has a substantial complication rate, and chest tube duration is a risk factor. In-hospital interventions might benefit patients with larger leaks that likely require prolonged OWD use. Because clamp trials occasionally fail, we contend that a clamp trial is the safest course before CT removal.

  View details for DOI 10.1245/s10434-024-15219-7

  View details for PubMedID 38536584

  View details for PubMedCentralID 6026238

• Lepidic-Type Lung Adenocarcinomas: Is It Safe to Observe for Growth Prior to Treating? The Annals of thoracic surgery Wong, L. Y., Elliott, I. A., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2024

  Abstract

  Lepidic-type adenocarcinomas (LPA) can be multi-focal, and treatment is often deferred until there is observed growth. This study investigated the potential downside of that strategy by evaluating the relationship of nodal involvement with tumor size and survival.The impact of tumor size on lymph node involvement and survival was evaluated for National Cancer Database patients who received surgery without induction therapy as primary treatment for cT1-3N0M0 histologically confirmed LPA from 2006-2019 using logistic regression, Kaplan-Meier, and Cox analyses.Positive nodes occurred in 442 (5.3%) of 8,286 patients. The incidence of having positive nodes approximately doubled with each 1cm increment increase in size. Patients with positive nodes were more likely to have larger tumors (27mm vs 20mm,p<0.001) and clinical T2+ disease (40.7% vs 26.8%,p<0.001) compared to node-negative patients, but tumor size was the only significant independent predictor of having positive nodal disease in logistic regression analysis; this association grew stronger with each incremental centimeter increase in size. Patients with positive nodes were more likely to undergo adjuvant radiation (23.5% vs 1.1%,p<0.001) and chemotherapy (72.9% vs 7.9%,p<0.001), and expectedly had worse survival compared to the node negative group in univariate (5-year overall survival 50.9% vs 81.1%,p<0.001) and multivariable (Hazard ratio 2.56 [95% CI 2.14-3.05],p<0.001) analyses.Nodal involvement is relatively uncommon in early-stage LPAs but steadily increases with tumor size and is associated with dramatically worse survival. This data can be used to inform treatment decisions when evaluating LPA patients.

  View details for DOI 10.1016/j.athoracsur.2024.03.003

  View details for PubMedID 38490310

• Outcomes of surgery for catastrophic hiatal hernia presentations. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Wong, L., Leipzig, M., Elliott, I. A., Liou, D. Z., Backhus, L. M., Shrager, J. B., Berry, M. F. 2024; 28 (3): 285-286

  View details for DOI 10.1016/j.gassur.2023.12.024

  View details for PubMedID 38445922

• The Impact of Immunotherapy Use in Stage IIIA (T1-2N2) NSCLC: A Nationwide Analysis. JTO clinical and research reports Wong, L. Y., Liou, D. Z., Roy, M., Elliott, I. A., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2024; 5 (3): 100654

  Abstract

  Multiple clinical trials have revealed the benefit of immunotherapy (IO) for NSCLC, including unresectable stage III disease. Our aim was to investigate the impact of IO use on treatment and outcomes of potentially resectable stage IIIA NSCLC in a broader nationwide patient cohort.We queried the National Cancer Database (2004-2019) for patients with stage IIIA (T1-2N2) NSCLC. Treatment and survival were evaluated with descriptive statistics, logistic regression, Kaplan-Meier analysis, and Cox proportional hazards modeling.Overall, 5.5% (3777 of 68,335) of patients received IO. IO use was uncommon until 2017, but by 2019, it was given to 40.1% (1544 of 2308) of stage IIIA patients. The increased use of IO after 2017 was associated with increased definitive chemoradiation treatment (54.2% [6800 of 12,535] from years 2017 to 2019 versus 46.9% [26,251 of 55,914] from 2004 to 2016, p < 0.001) and less use of surgery (18.1% [2266 of 12,535] from years 2017 to 2019 versus 22.0% [12,300 of 55,914] from 2004 to 2016, p < 0.001). IO treatment was associated with significantly better 5-year survival in the entire cohort (36.9% versus 23.4%, p < 0.001) and the subsets of patients treated with chemoradiation (37.2% versus 22.7%, p < 0.001) and surgery (48.6% versus 44.3%, p < 0.001). Pneumonectomy use decreased with increased IO treatment (5.1% of surgical patients [116 of 2266] from years 2017 to 2019 versus 9.2% [1127 of 12,300] from 2004 to 2016, p < 0.001).Increased use of IO was associated with a change in treatment patterns and improved survival for patients with stage IIIA(N2) NSCLC.

  View details for DOI 10.1016/j.jtocrr.2024.100654

  View details for PubMedID 38496376

  View details for PubMedCentralID PMC10941003

• Surgical revision of the postesophagectomy gastric conduit to address poor emptying. JTCVS techniques Wong, L., Rivera, M. F., Liou, D. Z., Berry, M. F. 2024; 23: 132-140

  Abstract

  Introduction: The configuration of the gastric conduit after esophagectomy can lead to chronic gastrointestinal and respiratory issues. Surgical revision of the gastric conduit has been described in small series but appears to be infrequently used. We investigated outcomes of revising dilated or redundant conduit in patients with severe quality-of-life issues.Methods: We identified all patients from 2016 to 2022 at our institution who underwent gastric conduit revision after previous esophagectomy either at our or another institution. Chart review was performed to assess prerevision course and perioperative outcomes. Pre- and postrevision imaging was compared for all patients to assess the impact of surgery on anatomic configuration. Patient-reported gastrointestinal and respiratory issues before and after surgery were examined.Results: The use of right thoracotomy combined with laparotomy to reduce redundancy and improve gastric emptying was performed in 8 patients. The symptoms necessitating reoperation included intolerance to oral intake and poor gastric emptying associated with both acute and chronic aspiration episodes. The median length of stay was 8 [4, 25] days, and there were no perioperative mortalities. Seven (87.5%) patients were tolerating oral intake at discharge. All patients had improvement in their prerevision symptoms on follow-up.Conclusions: Gastric conduit revision can improve severe postesophagectomy gastrointestinal and respiratory symptoms in patients with dilated/redundant conduits with limited perioperative morbidity.

  View details for DOI 10.1016/j.xjtc.2023.11.006

  View details for PubMedID 38351992

• Impact of guideline therapy on survival of patients with stage I-III epithelioid mesothelioma. Journal of thoracic disease Liou, D. Z., Wang, Y., Bhandari, P., Shrager, J. B., Lui, N. S., Backhus, L. M., Berry, M. F. 2023; 15 (12): 6661-6673

  Abstract

  Modern treatment guidelines recommend multimodal therapy with at least chemotherapy and surgery for patients with potentially resectable epithelioid mesothelioma. This study evaluated guideline compliance for patients with stage I-III epithelioid mesothelioma and tested the hypothesis that guideline-concordant therapy improved survival.The National Cancer Database was queried for patients with stage I-III epithelioid malignant pleural mesothelioma between 2004 and 2016. The impact of therapy was evaluated using logistic regression, Kaplan-Meier analysis, Cox-proportional hazards analysis, and propensity-scoring methods.During the study period, guideline-concordant therapy was used in 677 patients (19.1%), and 2,857 patients (80.8%) did not have guideline-concordant therapy. Younger age, being insured, living in a census tract with a higher income, clinical stage, and being treated at an academic or research program were all predictors of receiving guideline-concordant therapy in multivariable analysis. Guideline-concordant therapy yielded improved median survival [24.7 (22.4-26.1) vs. 13.7 (13.2-14.4) months] and 5-year survival [17.7% (14.7-21.3%) vs. 8.0% (7.0-9.3%)] (P<0.001), and continued to be associated with better survival in both multivariable analysis and propensity-matched analysis. In the patients who received guideline therapy, median survival [24.9 (21.9-27.2) vs. 24.5 (21.7-28.1) months] and 5-year survival [14.9% (10.9-20.2%) vs. 20.1% (16.0-25.4%)] was not significantly different between patients who underwent induction (n=304) versus adjuvant (n=373) chemotherapy (P=0.444).Guideline-concordant therapy for potentially resectable epithelioid mesothelioma is associated with significantly improved survival but used in a minority of patients. The timing of chemotherapy with surgery in this study did not have a significant impact on overall survival.

  View details for DOI 10.21037/jtd-23-1334

  View details for PubMedID 38249900

  View details for PubMedCentralID PMC10797401

• Risk of developing subsequent primary lung cancer after receiving radiation for breast cancer. JTCVS open Wong, L., Kapula, N., He, H., Guenthart, B. A., Vitzthum, L. K., Horst, K., Liou, D. Z., Backhus, L. M., Lui, N. S., Berry, M. F., Shrager, J. B., Elliott, I. A. 2023; 16: 919-928

  Abstract

  Background: Radiotherapy (RT) is integral to breast cancer treatment, especially in the current era that emphasizes breast conservation. The aim of our study was to determine the incidence of subsequent primary lung cancer after RT exposure for breast cancer over a time span of 3decades to quantify this risk over time as modern oncologic treatment continues to evolve.Methods: The SEER (Surveillance, Epidemiology, and End Results) database was queried from 1988 to 2014 for patients diagnosed with nonmetastatic breast cancer. Patients who subsequently developed primary lung cancer were identified. Multivariable regression modeling was performed to identify independent factors associated with the development of lung cancer stratified by follow up intervals of 5 to 9years, 10 to 15years, and >15years after breast cancer diagnosis.Results: Of the 612,746 patients who met our inclusion criteria, 319,014 (52%) were irradiated. primary lung cancer developed in 5556 patients (1.74%) in the RT group versus 4935 patients (1.68%) in the non-RT group. In a multivariable model stratified by follow-up duration, the overall HR of developing subsequent ipsilateral lung cancer in the RT group was 1.14 (P=.036) after 5 to 9years of follow-up, 1.28 (P=.002) after 10 to 15years of follow-up, and 1.30 (P=.014) after >15years of follow-up. The HR of contralateral lung cancer was not increased at any time interval.Conclusions: The increased risk of developing a primary lung cancer secondary to RT exposure for breast cancer is much lower than previously published. Modern RT techniques may have contributed to the improved risk profile, and this updated study is important for counseling and surveillance of breast cancer patients.

  View details for DOI 10.1016/j.xjon.2023.10.031

  View details for PubMedID 38204675

• Comparison of failure to rescue in younger versus elderly patients following lung cancer resection. JTCVS open Wang, Y., Kapula, N., Yang, C. J., Manapat, P., Elliott, I. A., Guenthart, B. A., Lui, N. S., Backhus, L. M., Berry, M. F., Shrager, J. B., Liou, D. Z. 2023; 16: 855-872

  Abstract

  Objective: Failure to rescue (FTR), defined as in-hospital death following a major complication, has been increasingly studied in patients who undergo cardiothoracic surgery. This study tested the hypothesis that elderly patients undergoing lung cancer resection have greater rates of FTR compared with younger patients.Methods: Patients who underwent surgery for primary lung cancer between 2011 and 2020 and had at least 1 major postoperative complication were identified using the National Surgical Quality Improvement Program database. Patients who died following complications (FTR) were compared with those who survived in an elderly (80+ years) and younger (<80years) cohort.Results: Of the 2823 study patients, the younger cohort comprised 2497 patients (FTR: n=139 [5.6%]), whereas the elderly cohort comprised 326 patients (FTR: n=39 [12.0%]). Pneumonia was the most common complication in younger (877/2497, 35.1%) and elderly patients (118/326, 36.2%) but was not associated with FTR on adjusted analysis. Increasing age was associated with FTR (adjusted odds ratio [AOR], 1.55 per decade, P<.001), whereas unplanned reoperation was associated with reduced risk (AOR, 0.55, P=.01). Within the elderly cohort, surgery conducted by a thoracic surgeon was associated with lower FTR risk (AOR, 0.29, P=.028).Conclusions: FTR following lung cancer resection was more frequent with increasing age. Pneumonia was the most common complication but not a predictor of FTR. Unplanned reoperation was associated with reduced FTR, as was treatment by a thoracic surgeon for elderly patients. Surgical therapy for complications after lung cancer resection and elderly patients managed by a thoracic specialist may mitigate the risk of death following an adverse postoperative event.

  View details for DOI 10.1016/j.xjon.2023.08.002

  View details for PubMedID 38204720

• The impact of refusing esophagectomy for treatment of locally advanced esophageal adenocarcinoma. JTCVS open Wong, L., Elliott, I. A., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2023; 16: 987-995

  Abstract

  Objective: Patients with esophageal cancer may be reluctant to proceed with surgery due to high complication rates. This study aims to compare outcomes between eligible surgical candidates who proceeded with surgery versus those who refused surgery.Methods: Characteristics and survival of patients with locally advanced (cT3N0M0, cT1-3N+M0) mid-/distal esophageal adenocarcinoma in the National Cancer Database (2006-2019) who either proceeded with or refused surgery after chemoradiotherapy were evaluated with logistic regression, Kaplan-Meier curves, and Cox proportional hazards methods.Results: Of the 13,594 patients included in the analysis, 595 (4.4%) patients refused esophagectomy. Patients who refused surgery were older, had less distance to travel to their treatment facility, were more likely to have cN0 disease, and were more likely to be treated at a community rather than academic or integrated network program, but did not have significantly different comorbid disease distributions. On multivariable analysis, refusing surgery was independently associated with older age, uninsured, lower income, less distance to a hospital, and treatment in a community program versus an academic/research or integrated network program. Esophagectomy was associated with better survival (5-year survival 40.1% [39.2-41] vs 23.6% [19.9-27.9], P<.001) and was also independently associated with better survival in the Cox model (hazard rate, 0.78 [95% confidence interval, 0.7-0.87], P<.001).Conclusions: The results of this study can inform selected patients with resectable esophageal adenocarcinoma that their survival will be significantly diminished if surgery is not pursued. Many factors associated with refusing surgery are non-clinical and suggest that access to or support for care could influence patient decisions.

  View details for DOI 10.1016/j.xjon.2023.09.006

  View details for PubMedID 38204633

• Impact of hyperthermic intrathoracic chemotherapy (HITHOC) during resection of pleural mesothelioma on patient survival. Journal of thoracic disease Elliott, I. A., He, H., Lui, N. S., Liou, D. Z., Guenthart, B. A., Shrager, J. B., Berry, M. F., Backhus, L. M. 2023; 15 (11): 6140-6150

  Abstract

  Pleural mesothelioma (PM) is rare but portends a poor prognosis. Multimodal treatment, including aggressive surgical resection, may offer the best chance of treatment response and improved survival. Single-center studies suggest that hyperthermic intrathoracic chemotherapy (HITHOC) during surgical resection improves outcomes, but the impact of HITHOC on postoperative morbidity and survival has not been examined on a larger scale.The National Cancer Database was queried for patients undergoing resection for PM from 2006-2017. Patients were excluded if staging or survival data was incomplete. After propensity-score matching, patients who underwent HITHOC were compared to patients who did not (case-control study). Perioperative outcomes and survival were analyzed.The final cohort consisted of 3,232 patients; of these, 365 patients underwent HITHOC. After propensity-score matching, receipt of HITHOC was associated with increased length of stay (12 vs. 7 days, P<0.001) and increased 30-day readmissions (9.9% vs. 4.9%, P=0.007), but decreased 30-day mortality (3.2% vs. 6.0%, P=0.017) and 90-day mortality (7.5% vs. 10.9%). Kaplan-Meier modeling demonstrated that HITHOC was associated with improved survival in the overall cohort (median 20.5 vs. 16.8 months, P=0.001). In multivariable analysis, HITHOC remained associated with improved overall survival [hazard ratio (HR) =0.80; 95% confidence interval (CI): 0.69-0.92; P=0.002], and this persisted in the propensity-matched analysis (HR =0.73; 95% CI: 0.61-0.88; P=0.001).Using a large national database, we describe the impact of HITHOC on survival in patients with PM. Despite observed increased short-term morbidity, in multivariable analysis HITHOC was associated with an overall survival advantage for patients undergoing surgical resection of PM.

  View details for DOI 10.21037/jtd-23-466

  View details for PubMedID 38090290

  View details for PubMedCentralID PMC10713319

• Impact of hyperthermic intrathoracic chemotherapy (HITHOC) during resection of pleural mesothelioma on patient survival JOURNAL OF THORACIC DISEASE Elliott, I. A., He, H., Lui, N. S., Liou, D. Z., Guenthart, B. A., Shrager, J. B., Berry, M. F., Backhus, L. M. 2023

  View details for DOI 10.21037/jtd-23-466

  View details for Web of Science ID 001101361100001

• Outcomes of a Failed Observation Approach for Paraesophageal Hernia Wong, L., Leipzig, M., Elliott, I. A., Lui, N., Liou, D., Backhus, L. M., Shrager, J. B., Berry, M. LIPPINCOTT WILLIAMS & WILKINS. 2023: S483

  View details for Web of Science ID 001094086301454

• Clinical Impact of EGFR vs KRAS Mutations in Multifocal Lung Adenocarcinoma Jiang, J., Berry, M. F., Lui, N. S., Liou, D. Z., Trope, W. L., Backhus, L. M., Shrager, J. B. ELSEVIER SCIENCE INC. 2023: S484-S485

  View details for Web of Science ID 001098831601318

• Outcomes of a Failed Observation Approach for Paraesophageal Hernia Wong, L., Leipzig, M., Elliott, I. A., Lui, N., Liou, D., Backhus, L. M., Shrager, J. B., Berry, M. LIPPINCOTT WILLIAMS & WILKINS. 2023: S483

  View details for Web of Science ID 001100379000036

• p53 governs an AT1 differentiation programme in lung cancer suppression. Nature Kaiser, A. M., Gatto, A., Hanson, K. J., Zhao, R. L., Raj, N., Ozawa, M. G., Seoane, J. A., Bieging-Rolett, K. T., Wang, M., Li, I., Trope, W. L., Liou, D. Z., Shrager, J. B., Plevritis, S. K., Newman, A. M., Van Rechem, C., Attardi, L. D. 2023

  Abstract

  Lung cancer is the leading cause of cancer deaths worldwide1. Mutations in the tumour suppressor gene TP53 occur in 50% of lung adenocarcinomas (LUADs) and are linked to poor prognosis1-4, but how p53 suppresses LUAD development remains enigmatic. We show here that p53 suppresses LUAD by governing cell state, specifically by promoting alveolar type 1 (AT1) differentiation. Using mice that express oncogenic Kras and null, wild-type or hypermorphic Trp53 alleles in alveolar type 2 (AT2) cells, we observed graded effects of p53 on LUAD initiation and progression. RNA sequencing and ATAC sequencing of LUAD cells uncovered a p53-induced AT1 differentiation programme during tumour suppression in vivo through direct DNA binding, chromatin remodelling and induction of genes characteristic of AT1 cells. Single-cell transcriptomics analyses revealed that during LUAD evolution, p53 promotes AT1 differentiation through action in a transitional cell state analogous to a transient intermediary seen during AT2-to-AT1 cell differentiation in alveolar injury repair. Notably, p53 inactivation results in the inappropriate persistence of these transitional cancer cells accompanied by upregulated growth signalling and divergence from lung lineage identity, characteristics associated with LUAD progression. Analysis of Trp53 wild-type and Trp53-null mice showed that p53 also directs alveolar regeneration after injury by regulating AT2 cell self-renewal and promoting transitional cell differentiation into AT1 cells. Collectively, these findings illuminate mechanisms of p53-mediated LUAD suppression, in which p53 governs alveolar differentiation, and suggest that tumour suppression reflects a fundamental role of p53 in orchestrating tissue repair after injury.

  View details for DOI 10.1038/s41586-023-06253-8

  View details for PubMedID 37468633

  View details for PubMedCentralID 4231481

• Tracheal stenosis and airway complications in the Coronavirus Disease-19 era. Annals of thoracic surgery short reports Krishnan, A., Guenthart, B. A., Choi, A., Trope, W., Berry, G. J., Pinezich, M. R., Vunjak-Novakovic, G., Shaller, B., Sung, C. K., Liou, D. Z., Damrose, E. J., Lui, N. S. 2023

  Abstract

  Severe Coronavirus Disease 2019 (COVID-19) infection is associated with prolonged intubation and its complications. Tracheal stenosis is one such complication that may require specialized surgical management. We aimed to describe the surgical management of post-COVID-19 tracheal stenosis.This case series describes consecutive patients with tracheal stenosis from intubation for severe COVID-19 infection at our single, tertiary academic medical center between January 1st, 2021, and December 31st, 2021. Patients were included if they underwent surgical management with tracheal resection and reconstruction, or bronchoscopic intervention. Operative through six-month, symptom-free survival and histopathological analysis of resected trachea were reviewed.Eight patients are included in this case series. All patients are female, and most (87.5%) are obese. Five patients (62.5%) underwent tracheal resection and reconstruction (TRR), while three patients (38.5%) underwent non-resection-based management. Among patients who underwent TRR, six-month symptom free survival is 80%; one patient (20%) required tracheostomy after TRR due to recurrent symptoms. Two of the three (66.7%) of patients who underwent non-resection-based management experienced durable relief from symptoms of tracheal stenosis with tracheal balloon dilation, and the remaining patient required laser excision of tracheal tissue prior to experiencing symptomatic relief.The incidence of tracheal stenosis may increase as patients recover from severe COVID-19 infection requiring intubation. Management of tracheal stenosis with TRR is safe and effective, with comparable rates of success to TRR for non-COVID-19 tracheal stenosis. Non-resection-based management is an option to manage tracheal stenosis in patients with less severe stenosis or in poor surgical candidates.

  View details for DOI 10.1016/j.atssr.2023.05.013

  View details for PubMedID 37360840

  View details for PubMedCentralID PMC10246306

• The impact of neoadjuvant immunotherapy on perioperative outcomes and survival after esophagectomy for esophageal cancer. JTCVS open Wong, L., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2023; 14: 547-560

  Abstract

  Objective: Immunotherapy for esophageal cancer is relatively novel but increasingly used. This study evaluated the early use of immunotherapy as an adjunct to neoadjuvant chemoradiotherapy before esophagectomy for locally advanced disease.Methods: Perioperative morbidity (composite of mortality, hospitalization ≥21days, or readmission) and survival of patients with locally advanced (cT3N0M0, cT1-3N + M0) distal esophageal cancer in the National Cancer Database from 2013 to 2020 who underwent neoadjuvant immunotherapy plus chemoradiotherapy or chemoradiotherapy alone followed by esophagectomy were evaluated using logistic regression, Kaplan-Meier curves, Cox proportional hazards methods, and propensity-matched analysis.Results: Immunotherapy was used in 165 (1.6%) of 10,348 patients. Younger age (odds ratio, 0.66; 95% confidence interval, 0.53-0.81; P<.001) predicted immunotherapy use, which slightly delayed time from diagnosis to surgery versus chemoradiation alone (immunotherapy 148 [interquartile range, 128-177] days vs chemoradiation 138 [interquartile range, 120-162] days, P<.001). There were no statistically significant differences between the immunotherapy and chemoradiation groups for the composite major morbidity index (14.5% [24/165] vs 15.6% [1584/10,183], P=.8). Immunotherapy was associated with a significant improvement in median overall survival (69.1months vs 56.3months, P=.005) and 3-year overall survival in univariate analysis (65.6% [95% confidence interval, 57.7-74.5] vs 55.0% [53.9-56.1], P=.005), and independently predicted improved survival in multivariable analysis (hazard ratio 0.68 [95% confidence interval, 0.52-0.89], P=.006). Propensity-matched analysis also showed that immunotherapy use was not associated with increased surgical morbidity (P=.5) but was associated with improved survival (P=.047).Conclusions: Neoadjuvant immunotherapy use before esophagectomy for locally advanced esophageal cancer did not lead to worse perioperative outcomes and shows promising results on midterm survival.

  View details for DOI 10.1016/j.xjon.2023.03.015

  View details for PubMedID 37425457

• ASO Visual Abstract: Treatment and Outcomes ofProximal Esophageal Squamous Cell Carcinoma. Annals of surgical oncology Patel, D. C., Yang, C. J., Liou, D. Z., Berry, M. F. 2023

  View details for DOI 10.1245/s10434-023-13628-8

  View details for PubMedID 37219657

• Characterization of Epidural Analgesia Interruption and Associated Outcomes After Esophagectomy. The Journal of surgical research Byrd, C. T., Kim, R. K., Manapat, P., He, H., Tsui, B. C., Shrager, J. B., Berry, M. F., Backhus, L. M., Lui, N. S., Liou, D. Z. 2023; 290: 92-100

  Abstract

  Interruption of thoracic epidural analgesia may impact the postoperative course following esophagectomy. This study investigates the incidence and causes of epidural interruption in esophagectomy patients along with associated postoperative outcomes.This single-institution retrospective analysis examined patients undergoing esophagectomy who received a thoracic epidural catheter from 2016 to 2020. Patients were stratified according to whether epidural catheter infusion was interrupted or not postoperatively. Outcomes were compared between the two groups, and predictors of epidural interruption and postoperative complications were estimated using multivariable logistic regression.Of the 168 patients who received a thoracic epidural before esophagectomy, 60 (35.7%) required epidural interruption and 108 (64.3%) did not. Interruption commonly occurred on postoperative day 1 and was due to hypotension 80% of the time. Heart failure (10.0% versus 0.9%, P = 0.009), atrial fibrillation (20.0% versus 3.7%, P = 0.002), preoperative opioid use (30.0% versus 16.7%, P = 0.043), and higher American Society of Anesthesiology classification (88.4% versus 70.4%, P = 0.008) were more prevalent in the epidural interruption cohort. The female gender was associated with epidural interruption on multivariable logistic regression (adjusted odds ratio [AOR] 2.45, P = 0.039). Patients in the epidural interruption cohort had a higher incidence of delirium (30.5% versus 13.9%, P = 0.010), sepsis (13.6% versus 3.7%, P = 0.028), and severe anastomotic leak (18.3% versus 7.4%, P = 0.032). On adjusted analysis, heart disease (AOR 4.26, P = 0.027), BMI <18.5 (AOR 9.83, P = 0.031), and epidural interruption due to hypotension (AOR 3.51, P = 0.037) were associated with severe anastomotic leak.Early epidural interruption secondary to hypotension in esophagectomy patients may be a harbinger of postoperative complications such as sepsis and severe anastomotic leak. Patients requiring epidural interruption due to hypotension should have a low threshold for additional workup and early intervention.

  View details for DOI 10.1016/j.jss.2023.04.009

  View details for PubMedID 37224609

• Surgical Management of Esophageal Perforation: Examining Trends in a Multi-Institutional Cohort. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Wong, L. Y., Leipzig, M., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2023

  Abstract

  Esophageal perforations historically are associated with significant morbidity and mortality and generally require emergent intervention. The influence of improved diagnostic and therapeutic modalities available in recent years on management has not been examined. This study examined the surgical treatments and outcomes of a modern cohort.Patients with esophageal perforation management in the 2005-2020 American College of Surgeons National Surgical Quality Improvement Program database were stratified into three eras (2005-2009, 2010-2014, and 2015-2020). Surgical management was classified as primary repair, resection, diversion, or drainage alone based on procedure codes. The distribution of procedure use, morbidity, and mortality across eras was examined.Surgical management of 378 identified patients was primary repair (n=193,51%), drainage (n=89,24%), resection (n=70,18%), and diversion (n=26,7%). Thirty-day mortality in the cohort was 9.5% (n=36/378) and 268 patients (71%) had at least one complication. The median length of stay was 15 days. Both morbidity (Era 1 65% [n=42/60] versus Era 2 69% [n=92/131] versus Era 3 72% [n=135/187], p=0.3) and mortality (Era 1 11% [n=7/65] versus Era 2 9% [n=12/131] versus Era 3 10% [n=19/187], p=0.9) did not change significantly over the three defined eras. Treatment over time evolved such that primary repair was more frequently utilized (43% in Era 1 to 51% in Era 3) while diversion was less often performed (13% in Era 1 to 7% in Era 3) (p=0.009).Esophageal perforation management in recent years uses diversion less often but remains associated with significant morbidity and mortality.

  View details for DOI 10.1007/s11605-023-05700-1

  View details for PubMedID 37165161

  View details for PubMedCentralID 7330325

• ASO Visual Abstract: Impact of Delaying Surgery After Chemoradiation on Outcomes for Locally Advanced Esophageal Squamous Cell Carcinoma. Annals of surgical oncology Wong, L. Y., Liou, D. Z., Vitzthum, L. K., Backhus, L. M., Lui, N. S., Chang, D., Shrager, J. B., Berry, M. F. 2023

  View details for DOI 10.1245/s10434-023-13156-5

  View details for PubMedID 36759429

• Does delaying surgery following induction chemotherapy compromise survival in patients with mesothelioma? JOURNAL OF CANCER METASTASIS AND TREATMENT Wong, L., Baiu, I., Leipzig, M., Titan, A., Liou, D. Z., Lui, N., Berry, M., Shrager, J. B., Backhus, L. 2023; 9

  View details for DOI 10.20517/2394-4722.2023.57

  View details for Web of Science ID 001072777600001

• Impact of Delaying Surgery After Chemoradiation on Outcomes for Locally Advanced Esophageal Squamous Cell Carcinoma. Annals of surgical oncology Wong, L., Liou, D. Z., Vitzthum, L. K., Backhus, L. M., Lui, N. S., Chang, D., Shrager, J. B., Berry, M. F. 2022

  Abstract

  BACKGROUND: Performing selective esophagectomy for locally advanced squamous cell carcinoma may spare patients morbidity, but delayed surgery may infer higher risks. This study evaluated the impact of length of time between chemoradiation and esophagectomy on perioperative outcomes and long-term survival.METHODS: The impact of surgical timing, stratified by surgery performed < 180 and ≥ 180 days from starting radiation, on perioperative outcomes and survival in patients treated with chemoradiation and esophagectomy for cT1N + M0 and cT2-4, any N, M0 squamous cell carcinoma of the mid-distal esophagus in the National Cancer Database (2006-2016) was evaluated with logistic regression, Kaplan-Meier curves, Cox proportional-hazards methods, and propensity-matched analysis.RESULTS: Median time between starting radiation and esophagectomy in 1641 patients was 93 (IQR 81-114) days. Most patients (96.8%, n = 1589) had surgery within 180 days of starting radiation, while 52 patients (3.2%) had delayed surgery. Black race and clinical T stage were associated with delayed surgery. Rates of pathologic upstaging, downstaging, complete response, and positive margins were not significantly different between the groups. Patients with delayed surgery had increased major morbidity as measured by a composite of length of hospital stay, readmission, and 30-day mortality [42.3% (22/52) vs 22.3% (355/1589), p = 0.001]. However, delayed surgery was not associated with a significant difference in survival in both univariate [5-year survival 32.8% (95% CI 21.1-50.7) vs 47.3% (44.7-50.1), p = 0.19] and multivariable analysis [hazard ratio (HR) 1.23 (0.85-1.78), p = 0.26].CONCLUSIONS: Delaying surgery longer than 180 days after starting chemoradiation for esophageal squamous cell carcinoma is associated with worse perioperative outcomes but not long-term survival.

  View details for DOI 10.1245/s10434-022-12980-5

  View details for PubMedID 36572807

• Safety and feasibility of minimally invasive lobectomy after neoadjuvant immunotherapy for non-small cell lung cancer. The Journal of thoracic and cardiovascular surgery Mathey-Andrews, C., McCarthy, M., Potter, A. L., Beqari, J., Wightman, S. C., Liou, D., Raman, V., Jeffrey Yang, C. 2022

  Abstract

  OBJECTIVE: The objective of this study was to evaluate the feasibility of minimally invasive surgery (MIS) and perioperative outcomes following neoadjuvant immunotherapy for resectable non-small cell lung cancer (NSCLC).METHODS: Patients with stage I to III NSCLC treated with immunotherapy with or without chemotherapy or chemotherapy alone prior to lobectomy were identified in the National Cancer Database (2010-2018). The percentage of operations performed minimally invasively, conversion rates, and perioperative outcomes were evaluated using propensity-score matching. Propensity-score matching was also used to compare perioperative outcomes between patients who underwent an open lobectomy and those who underwent an MIS lobectomy after neoadjuvant immunotherapy.RESULTS: Of the 4229 patients identified, 218 (5%) received neoadjuvant immunotherapy and 4011 (95%) received neoadjuvant chemotherapy alone. There was no difference in the rate of MIS lobectomy among patients who received immunotherapy compared with those who received chemotherapy alone in propensity score-matched analysis (60.8% vs 51.6%; P=.11). There also were no significant differences in the rate of conversion from MIS to open lobectomy (14% vs 15%, P=.83; odds ratio, 1.1; 95% confidence interval, 0.51-2.24) or in nodal downstaging, margin positivity, 30-day readmission, and 30- and 90-day mortality between the 2 groups. In a subgroup analysis of only patients treated with neoadjuvant immunotherapy, there were no differences in pathologic or perioperative outcomes between patients who underwent open lobectomy and those who underwent MIS lobectomy.CONCLUSIONS: In this national analysis, neoadjuvant immunotherapy for resectable NSCLC was not associated with an increased likelihood of the need for thoracotomy, conversion from MIS to open lobectomy, or inferior perioperative outcomes.

  View details for DOI 10.1016/j.jtcvs.2022.12.006

  View details for PubMedID 36653251

• Risk of adenocarcinoma in patients with a suspicious ground-glass opacity: a retrospective review. Journal of thoracic disease Roy, E., Shrager, J., Benson, J., Trope, W. L., Bhandari, P., Lui, N., Liou, D., Backhus, L., Berry, M. F. 2022; 14 (11): 4236-4245

  Abstract

  Both primary lung adenocarcinoma and benign processes can have a ground-glass opacity (GGO) appearance on imaging. This study evaluated the incidence of and risk factors for malignancy in a diverse cohort of patients who underwent resection of a GGO suspicious for lung cancer.All patients who underwent resection of a pulmonary nodule with a GGO component and suspected to be primary lung cancer at a single institution from 2001-2017 were retrospectively reviewed. Risk factors for malignancy were evaluated using multivariable logistic regression analysis that included nodule size, age, sex, and race as potential predictors.The incidence of pulmonary adenocarcinoma in the 243 patients who met inclusion criteria was 86% (n=208). The most common pathologic findings in 35 patients with a benign pathology was granulomatous inflammation (n=14, 40%). Risk factors for adenocarcinoma in multivariable logistic regression were age [odds ratio (OR) 1.06, P=0.003], GGO size (OR 2.76, P<0.001), female sex (OR 4.47, P=0.002), and Asian race (OR 8.35, P=0.002). In this cohort, adenocarcinoma was found in 100% (44/44) of Asian females, 86% (25/29) of Asian males, 84% (98/117) of non-Asian females, and 77% (41/53) of non-Asian males.The likelihood of adenocarcinoma in lung nodules with a ground-glass component is influenced by sex and race. Asian females with a GGO have a much higher likelihood of having adenocarcinoma than men and non-Asians. This data can be used when deciding whether to pursue nodule resection or surveillance in a patient with a GGO.

  View details for DOI 10.21037/jtd-22-583

  View details for PubMedID 36524073

  View details for PubMedCentralID PMC9745528

• Treatment and Outcomes of Proximal Esophageal Squamous Cell Carcinoma. Annals of surgical oncology Patel, D. C., Yang, C. J., Liou, D. Z., Berry, M. F. 2022

  Abstract

  INTRODUCTION: This study evaluated the treatment of proximal (cervical or upper thoracic) esophageal squamous cell carcinoma (SCC), for which chemoradiation is the recommended therapy.METHODS: Treatment and outcomes of patients with cT1-3N0-1M0 proximal esophageal SCC in the National Cancer Database between 2004 and 2016 was evaluated using logistic regression, Kaplan-Meier analysis, and propensity-score matching.RESULTS: Therapy of 2159 patients was chemoradiation (n=1500, 69.5%), no treatment (n=205, 9.5%), surgery (n=203, 9.4%), radiation alone (n=190, 8.8%), and chemotherapy alone (n=61, 2.8%). Factors associated with definitive therapy with either chemoradiation or surgery were younger age, non-Black race, being insured, cervical tumor location, clinical T2 and T3 stage, clinical nodal involvement, and treatment at a research/academic program. Five-year survival was significantly better in patients treated with definitive therapy than patients not treated definitively (34.0% vs. 13.3%, p<0.001). In multivariable survival analysis, receiving definitive therapy (hazard ratio [HR] 0.39, p=0.017) was associated with improved survival, while increasing age, male sex, clinical T3 stage, positive clinical nodal involvement, and increasing Charlson Comorbidity Index were associated with worse survival. Esophagectomy was not associated with improved survival in multivariable analysis of the definitive therapy cohort (HR 0.84, p=0.08) or propensity matched analysis. However, the pathologic complete response was only 33.3% (40/120) for patients who did have an esophagectomy after chemoradiation.CONCLUSIONS: This national analysis supports definitive chemoradiation for not only cervical but also proximal thoracic esophageal SCC. Routine surgery does not appear to be necessary but may have a role in patients with residual disease after chemoradiation.

  View details for DOI 10.1245/s10434-022-12683-x

  View details for PubMedID 36305985

• Lobar versus sublobar resection in clinical stage IA primary lung cancer with occult N2 disease. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery Liou, D. Z., Chan, M., Bhandari, P., Lui, N. S., Backhus, L. M., Shrager, J. B., Berry, M. F. 2022

  Abstract

  Sublobar resection is increasingly being utilized for early-stage lung cancers, but optimal management when final pathology shows unsuspected mediastinal nodal disease is unclear. This study tested the hypothesis that lobectomy has improved survival compared to sublobar resection for clinical stage IA tumors with occult N2 disease.The use of sublobar resection and lobectomy for patients in the National Cancer Database who underwent primary surgical resection for clinical stage IA non-small cell lung cancer with pathologic N2 disease between 2010 and 2017 was evaluated using logistic regression. Survival was assessed with Kaplan-Meier analysis, log-rank test, and Cox proportional hazards model.A total of 2,419 patients comprised the study cohort, including 320 sublobar resections (13.2%) and 2,099 lobectomies (86.8%). Older age, female sex, smaller tumour size, and treatment at an academic facility predicted the use of sublobar resection. Patients undergoing lobectomy had larger tumors (2.40 vs 2.05 cm, p < 0.001) and more lymph nodes examined (11 vs 5, p < 0.001). Adjuvant chemotherapy use was similar between the two groups (sublobar 79.4% vs lobectomy 77.4%, p = 0.434). Sublobar resection was not associated with worse survival compared to lobectomy in both univariate (5-year survival 46.6% vs 45.2%, p = 0.319) and multivariable Cox proportional hazards analysis (HR 0.97, p = 0.789).Clinical stage IA non-small cell lung cancer patients with N2 disease on final pathology have similar long-term survival with either sublobar resection or lobectomy. Patients with occult N2 disease after sublobar resection may not require reoperation for completion lobectomy but should instead proceed to adjuvant chemotherapy.

  View details for DOI 10.1093/ejcts/ezac440

  View details for PubMedID 36063054

• Risk of adenocarcinoma in patients with a suspicious ground-glass opacity: a retrospective review JOURNAL OF THORACIC DISEASE Roy, E., Shrager, J., Benson, J., Trope, W., Bhandari, P., Lui, N., Liou, D., Backhus, L., Berry, M. F. 2022

  View details for DOI 10.21037/jtd-22-583

  View details for Web of Science ID 000869953800001

• Eligibility for Lung Cancer Screening Among Women Receiving Screening for Breast Cancer. JAMA network open Titan, A. L., Baiu, I., Liou, D., Lui, N. S., Berry, M., Shrager, J., Backhus, L. 2022; 5 (9): e2233840

  View details for DOI 10.1001/jamanetworkopen.2022.33840

  View details for PubMedID 36178692

• Multimodal Management of T4 N2 Non-small-cell Lung Cancer with Additional Ipsilateral Pulmonary Nodules Kumar, A., Kumar, S., Potter, A., Gilja, S., Liou, D., Yang, C. J. ELSEVIER SCIENCE INC. 2022: S7

  View details for Web of Science ID 000858678100011

• Commentary: A guide for what we know and what still needs to be learned. The Journal of thoracic and cardiovascular surgery Liou, D. Z. 2022

  View details for DOI 10.1016/j.jtcvs.2022.06.020

  View details for PubMedID 35931581

• Half of Anastomotic Leaks after Esophagectomy are Undetected on Initial Postoperative Esophagram. The Annals of thoracic surgery Elliott, I. A., Berry, M. F., Trope, W., Lui, N. S., Guenthart, B. A., Liou, D. Z., Whyte, R. I., Backhus, L. M., Shrager, J. B. 2022

  Abstract

  The sensitivity of fluoroscopic esophagrams with oral contrast to exclude anastomotic leak after esophagectomy is not well-documented, and the consequences of missing a leak in this setting have not been previously described.We performed a retrospective cohort study of a prospectively maintained institutional database of patients undergoing esophagectomy with esophagogastric anastomosis 2008-2020. Relevant details regarding leaks, management, and outcomes were obtained from the database and formal chart review. Statistical analysis was performed to compare patients with and without leaks, and those with false negative versus positive esophagrams.There were 384 patients who underwent esophagectomy with gastric reconstruction: the majority were Ivor-Lewis (82%), and 51% were wholly or partially minimally-invasive. Using a broad definition of leak, 55 patients (16.7%) developed an anastomotic leak. Twenty-seven of the 55 patients (49%) who ultimately were found to have a leak initially had a negative esophagram (performed on average on postoperative day 6). Those with a negative initial esophagram were more likely to have an uncontained leak (81% vs. 29%, p<0.01), require unplanned readmission (70% vs. 39%, p=0.02), and undergo reoperation (44% vs. 11%, p<0.01).Early postoperative esophagrams intended to evaluate anastomotic integrity have a low sensitivity of 51%, and leaks missed on initial esophagram have greater clinical consequences than those identified on initial esophagram. These findings suggest a high index of suspicion must be maintained even after a normal esophagram and calls into question the common practice of using this test to triage patients for diet advancement.

  View details for DOI 10.1016/j.athoracsur.2022.04.053

  View details for PubMedID 35618049

• Positron emission tomography/computed tomography differentiates resectable thymoma from anterior mediastinal lymphoma. The Journal of thoracic and cardiovascular surgery Byrd, C. T., Trope, W. L., Bhandari, P., Konsker, H. B., Moradi, F., Lui, N. S., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B. 2022

  Abstract

  OBJECTIVE: Discrete anterior mediastinal masses most often represent thymoma or lymphoma. Lymphoma treatment is nonsurgical and requires biopsy. Noninvasive thymoma is ideally resected without biopsy, which may potentiate pleural metastases. This study sought to determine if clinical criteria or positron emission tomography/computed tomography could accurately differentiate the 2, guiding a direct surgery versus biopsy decision.METHODS: A total of 48 subjects with resectable thymoma and 29 subjects with anterior mediastinal lymphoma treated from 2006 to 2019 were retrospectively examined. All had pretreatment positron emission tomography/computed tomography and appeared resectable (solitary, without clear invasion or metastasis). Reliability of clinical criteria (age and B symptoms) and positron emission tomography/computed tomography maximum standardized uptake value were assessed in differentiating thymoma and lymphoma using Wilcoxon rank-sum test, chi-square test, and logistic regression. Receiver operating characteristic analysis identified the maximum standardized uptake value threshold most associated with thymoma.RESULTS: There was no association between tumor type and age group (P=.183) between those with thymoma versus anterior mediastinal lymphoma. Patients with thymoma were less likely to report B symptoms (P<.001). The median maximum standardized uptake value of thymoma and lymphoma differed dramatically: 4.35 versus 18.00 (P<.001). Maximum standardized uptake value was independently associated with tumor type on multivariable regression. On receiver operating characteristic analysis, lower maximum standardized uptake value was associated with thymoma. Maximum standardized uptake value less than 12.85 was associated with thymoma with 100.00% sensitivity and 88.89% positive predictive value. Maximum standardized uptake value less than 7.50 demonstrated 100.00% positive predictive value for thymoma.CONCLUSIONS: Positron emission tomography/computed tomography maximum standardized uptake value of resectable anterior mediastinal masses may help guide a direct surgery versus biopsy decision. Tumors with maximum standardized uptake value less than 7.50 are likely thymoma and thus perhaps appropriately resected without biopsy. Tumors with maximum standardized uptake value greater than 7.50 should be biopsied to rule out lymphoma. Lymphoma is likely with maximum standardized uptake value greater than 12.85.

  View details for DOI 10.1016/j.jtcvs.2022.02.055

  View details for PubMedID 35568521

• A national analysis of open versus minimally invasive thymectomy for stage I-III thymic carcinoma. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery Hurd, J., Haridas, C., Potter, A., Baiu, I., Beqari, J., Deng, J., Liou, D., Patel, D., Yang, C. J. 2022

  Abstract

  The oncological efficacy of minimally invasive thymectomy for thymic carcinoma is not well characterized. We compared overall survival and short-term outcomes between open and minimally invasive surgical (video-assisted thoracoscopic and robotic) approaches using the National Cancer Database.Perioperative outcomes and overall survival of patients who underwent open versus minimally invasive thymectomy for Masaoka stage I-III thymic carcinoma from 2010 to 2015 in the National Cancer Database were evaluated using propensity score-matched analysis and multivariable Cox proportional hazards modelling. Outcomes by surgical approach were assessed using an intent-to-treat analysis.Of the 216 thymectomies that were evaluated, 43 (20%) were performed with minimally invasive techniques (22 video-assisted thoracoscopic and 21 robotic). The minimally invasive approach was associated with a shorter median length of stay when compared to the open approach (3 vs 5 days, P < 0.001). In the propensity score-matched analysis of 30 open and 30 minimally invasive thymectomies, the minimally invasive group did not differ significantly in median length of stay (3 vs 4.5 days, P = 0.27), 30-day readmission (P = 0.13), 30-day mortality (P = 0.60), 90-day mortality (P = 0.60), margin positivity (P = 0.39) and 5-year survival (78.6% vs 54.6%, P = 0.15) when compared to the open group.In this national analysis, minimally invasive thymectomy for stage I-III thymic carcinoma was found to have no significant differences in short-term outcomes and overall survival when compared to open thymectomy.

  View details for DOI 10.1093/ejcts/ezac159

  View details for PubMedID 35259241

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

  Abstract

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

  View details for DOI 10.1016/j.athoracsur.2021.07.058

  View details for PubMedID 34425099

• Surgical resection for patients with pulmonary aspergillosis in the national inpatient sample. Journal of thoracic disease Patel, D. C., Bhandari, P., Epstein, D. J., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B., Lui, N. S. 2021; 13 (8): 4977-4987

  Abstract

  The role of lung resection in patients with pulmonary aspergillosis is generally reserved for those with localized disease who fail medical management. We used a national database to investigate the influence of preoperative patient comorbidities on inpatient mortality and need for surgery.Patients admitted with pulmonary aspergillosis between 2007 to 2015 were identified in the National Inpatient Sample dataset. Inpatient mortality rates were compared between patients treated medically and surgically. Predictors of mortality, surgical intervention, and non-elective admission were evaluated using multivariable logistic regression.Among a population estimate of 112,998 patients with pulmonary aspergillosis, 107,606 (95.2%) underwent medical management alone and 5,392 (4.8%) underwent surgical resection. Positive predictors for surgery included hemoptysis, and history of lung cancer or chronic pulmonary diseases. Surgically treated patients had a lower inpatient mortality when compared to those treated medically (11.5% vs. 15.1%, P<0.001) in univariate analysis, but this finding did not persist in multivariable analysis (AOR 0.97, P=0.509). The odds of mortality were lower in patients undergoing video assisted thoracoscopic surgery compared to an open approach (AOR 0.77, P=0.001). Among patients treated surgically, mortality was higher in those with a history of lung cancer, solid organ transplantation, liver disease, human immunodeficiency virus infection, hematologic diseases, chronic pulmonary diseases, and those admitted non-electively requiring surgery.In this generalizable study, medical and surgical management of pulmonary aspergillosis were comparable in terms of inpatient mortality. However, non-elective admission and patients with select comorbidities have significantly worse outcomes after surgical intervention.

  View details for DOI 10.21037/jtd-21-151

  View details for PubMedID 34527336

  View details for PubMedCentralID PMC8411153

• Short-term and intermediate-term readmission after esophagectomy. Journal of thoracic disease Wang, Y., Yang, C. J., He, H., Buchan, J. M., Patel, D. C., Liou, D. Z., Lui, N. S., Berry, M. F., Shrager, J. B., Backhus, L. M. 2021; 13 (8): 4678-4689

  Abstract

  The objective of this study was to characterize short- and intermediate-term readmissions following esophagectomy and to identify predictors of readmission in these two groups.Patients who underwent esophagectomy in the National Readmissions Database (2013-2014) were grouped according to whether first readmission was "short-term" (readmitted <30 days) or "intermediate-term" (readmitted 31-90 days) following index admission for esophagectomy. Predictors of readmission were evaluated using multivariable logistic regression modeling.Of the 3,005 patients who underwent esophagectomy, 544 (18.1%) had a short-term readmission and 305 (10.1%) had an intermediate-term readmission. The most frequent reasons for short-term readmission were post-operative infection (7.5%), dysphagia (6.3%) and pneumonia (5.1%). The most common intermediate-term complications were pneumonia (7.2%), gastrointestinal stricture/stenosis (6.9%) and dysphagia (5.9%). In multivariable analysis, being located in a micropolitan area, increasing number of comorbidities and higher severity of illness score were associated with an increased likelihood of having a short-term readmission while being discharged to a facility (as opposed to directly home) was associated with increased likelihood of both short- and intermediate-term readmission (all P<0.05).In this analysis, postoperative infection was the most common reason for short-term readmission. Dysphagia and pneumonia were common reasons for both short- and intermediate-term readmission of patients following esophagectomy. Interventions focused on reducing the risk of postoperative infection and pneumonia may reduce hospital readmissions. Gastrointestinal stricture and dysphagia were associated with increased risk of intermediate readmission and should be examined in the context of morbidity associated with pyloric procedures (e.g., pyloromyotomy) at the time of esophagectomy.

  View details for DOI 10.21037/jtd-21-637

  View details for PubMedID 34527309

  View details for PubMedCentralID PMC8411130

• The Impact of Extended Delayed Surgery for Indolent Lung Cancer or Part-solid Ground Glass Nodules. The Annals of thoracic surgery Mayne, N. R., Elser, H., Lin, B. K., Raman, V., Liou, D., Li, X., D'Amico, T. A., Yang, C. J. 2021

  Abstract

  BACKGROUND: During the COVID-19 pandemic, patients with lung cancer may experience treatment delays. The objective of this study was to evaluate the impact of extended treatment delays on survival among patients with stage I typical bronchopulmonary carcinoid (BC), lepidic predominant adenocarcinoma (LPA) or invasive adenocarcinoma with a lepidic component (ADL).METHODS: Using National Cancer Data Base data (2004-2015), multivariable Cox regression analysis with penalized smoothing splines was performed to examine the association between treatment delay and all-cause mortality for stage I BC, LPA and ADL. Propensity score-matched analyses compared the overall survival in patients who received "early" versus "delayed" surgery (i.e. 0-30 versus 90-120 days following diagnosis) across the different histologic subtypes.RESULTS: During the study period, patients with stage I BC (n=4,947), LPA (n=5,340) and ADL (n=6,816) underwent surgery. Cox regression analysis of these cohorts showed a gradual steady increase in the hazard ratio the longer treatment is delayed. However, in propensity score-matched analyses which created cohorts of patients who underwent early and delayed surgery that were well-balanced in patient characteristics, no significant differences in 5-year survival were found between early and delayed surgery for stage I BC (87% [95% CI:77-93] vs 89% [95% CI:80-94]), stage I LPA (73% [95% CI:64-80] vs 77% [95% CI:68-83]) and stage I ADL (71% [95% CI:64-76] vs 69% [95% CI:60-76]).CONCLUSIONS: During the COVID-19 pandemic, for early-stage indolent lung tumors and part-solid ground glass lung nodules, a delay of surgery by 3-4 months following diagnosis can be considered.

  View details for DOI 10.1016/j.athoracsur.2021.05.099

  View details for PubMedID 34329603

• Surgical resection for patients with pulmonary aspergillosis in the national inpatient sample JOURNAL OF THORACIC DISEASE Patel, D. C., Bhandari, P., Epstein, D. J., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B., Lui, N. S. 2021

  View details for DOI 10.21037/jtd-21-151

  View details for Web of Science ID 000684526500001

• Reconsidering the American Joint Committee on Cancer 8th Edition TNM Staging Manual Classifications for T2b/T3 Non-small-cell Lung Cancer. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer Kumar, A., Kumar, S., Gilja, S., Potter, A., Raman, V., Muniappan, A., Liou, D., Jeffrey Yang, C. 2021

  Abstract

  INTRODUCTION: The American Joint Committee on Cancer (AJCC) 8th edition TNM staging manual for non-small-cell lung cancer (NSCLC), derived from the International Association for the Study of Lung Cancer (IASLC) Staging Project, designates tumors with additional nodule(s) in the same lobe as T3. This study sought to externally validate IASLC results, which showed a trend in improved survival for such tumors but excluded treatment-based adjustment, by assessing whether these tumors have worse survival than T2b NSCLC.METHODS: Overall survival of patients with T2b-T3, N0-3, M0 NSCLC (satisfying a single T descriptor of "T2b" [>4cm but ≤5cm in greatest dimension], "T3-size" [>5cm but ≤7cm in greatest dimension] or "T3-Add" [additional nodule(s) in the same lobe]), according to the AJCC 8th edition, in the National Cancer Data Base (2010-2015) was evaluated using multivariable Cox proportional hazards modeling and propensity score matching.RESULTS: 31,563 patients with T2b-T3, N0-3, M0 NSCLC met the study inclusion criteria. In multivariable-adjusted analysis, T3-Add tumors had improved overall survival compared to T3-Size tumors (HR: 0.86, 95% CI: 0.82-0.89, p<0.001), and similar survival compared to T2b tumors (HR: 1.04, 95% CI: 0.97-1.12, p=0.28). A propensity score-matched analysis of 2,260 T3-Add and 2,260 T2b patients, well-balanced on 16 common prognostic covariates, including treatment type (surgery, chemotherapy and/or radiation), demonstrated similar 5-year survival (53.4% vs 52.3%, p=0.30).CONCLUSIONS: In this national analysis, T3-Add tumors had better survival than other T3 tumors and similar survival to T2b tumors. These findings may be taken into consideration for the AJCC 9th edition staging classifications.

  View details for DOI 10.1016/j.jtho.2021.06.016

  View details for PubMedID 34242788

• Short-term and intermediate-term readmission after esophagectomy JOURNAL OF THORACIC DISEASE Wang, Y., Yang, C., He, H., Buchan, J. M., Patel, D. C., Liou, D. Z., Lui, N. S., Berry, M. F., Shrager, J. B., Backhus, L. M. 2021

  View details for DOI 10.21037/jtd-21-637

  View details for Web of Science ID 000682802900001

• Early Discharge after Lobectomy for Lung Cancer does not Equate to Early Readmission. The Annals of thoracic surgery Patel, D. C., Leipzig, M., Jeffrey Yang, C., Wang, Y., Shrager, J. B., Backhus, L. M., Lui, N. S., Liou, D. Z., Berry, M. F. 2021

  Abstract

  BACKGROUND: Enhanced recovery after surgery (ERAS) pathways in several specialties reduce length of stay, but accelerated discharge after thoracic surgery is not well characterized. This study tested the hypothesis that patients discharged on post-operative day 1 (POD1) after lobectomy for lung cancer have an increased risk of readmission.METHODS: Patients who underwent a lobectomy for lung cancer between 2011-2019 in the American College of Surgeons National Surgical Quality Improvement Program database were identified. Readmission rates were compared between patients discharged on postoperative day 1 (POD1) and patients discharged POD 2-6. Early discharge and readmission predictors were evaluated using multivariable logistic regression analysis.RESULTS: Only 854 (3.8%) of 22,585 patients that met inclusion criteria were discharged on POD1, though POD1 discharge rates increased from 2.3% to 8.1% (p< 0.001) from 2011 to 2019. Median hospitalization for POD2-6 patients was 4 days (IQR: 3-5). Patient characteristics associated with a lower likelihood of POD1 discharge were increasing age, smokers, or history of dyspnea, while a minimally invasive approach was the strongest predictor of early discharge (AOR 5.42, p<0.001). Readmission rates were not significantly different for POD1 and POD2-6 groups in univariate analysis (6.0% vs 7.0%, p=0.269). Further, POD1 discharge was not a risk factor for readmission in multivariable analysis (AOR 1.10, p=0.537).CONCLUSIONS: Select patients can be discharged on POD1 after lobectomy for lung cancer without an increased readmission risk, supporting this accelerated discharge target inclusion in lobectomy ERAS protocols.

  View details for DOI 10.1016/j.athoracsur.2021.05.053

  View details for PubMedID 34126077

• Influence of facility volume on long-term survival of patients undergoing esophagectomy for esophageal cancer. The Journal of thoracic and cardiovascular surgery Patel, D. C., Jeffrey Yang, C., He, H., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2021

  Abstract

  OBJECTIVE: This study investigated the influence of facility volume on long-term survival in patients with esophageal cancer treated with esophagectomy.METHODS: Patients treated with esophagectomy for cT1 3N0 3M0 adenocarcinoma or squamous cell carcinoma of the mid-distal esophagus in the National Cancer Database between 2006 and 2013 were stratified by annual facility esophagectomy volume dichotomized as more/less than both 6 and 20. Patient characteristics associated with facility volume were evaluated using logistic regression, and the influence of facility volume on survival was evaluated with Kaplan-Meier curves, Cox proportional hazards methods, and propensity matched analysis.RESULTS: Of 11,739 patients who had esophagectomy at 1018 facilities where annual volume ranged from 1 to 47.6 cases, 4262 (36.3%) were treated at 44 facilities with annual esophagectomy volume>6 and 1515 (12.9%) were treated at 7 facilities with annual volume>20. Higher volume was associated with significantly better 5-year survival for both annual volume > 6 (47.6% vs 40.2%; P<.001) and annual volume>20 (47.2% vs 42.3%; P<.001), which persisted in propensity matched analyses as well as Cox multivariable analysis (hazard ratio, 0.81; 95% confidence interval, 0.74-0.89; P<.001 for facility volume>6 and hazard ratio, 0.78; 95% confidence interval, 0.65-0.95; P=.01 for facility volume>20). In Cox multivariable analysis that considered facility volume as a continuous variable, higher volume continued to be associated with better survival (hazard ratio, 0.93 per 5 cases; 95% CI, 0.91-0.96; P<.001).CONCLUSIONS: Esophageal cancer patients treated with esophagectomy at higher volume facilities have significantly better long-term survival than patients treated at lower volume facilities.

  View details for DOI 10.1016/j.jtcvs.2021.05.048

  View details for PubMedID 34247867

• A new model using artificial intelligence to predict recurrence after surgical resection of stage I-II non-small cell lung cancer. Lui, N., Wei, N., Trope, W., Nesbit, S., Bhandari, P., Lee, C., Hu, H., Guo, H., Liou, D. Z., Shrager, J. B., Backhus, L., Berry, M. F., Yang, E. LIPPINCOTT WILLIAMS & WILKINS. 2021

  View details for DOI 10.1200/JCO.2021.39.15_suppl.8537

  View details for Web of Science ID 000708120604251

• Cancer diagnoses and survival rise as 65-year-olds become Medicare-eligible. Cancer Patel, D. C., He, H., Berry, M. F., Yang, C. J., Trope, W. L., Wang, Y., Lui, N. S., Liou, D. Z., Backhus, L. M., Shrager, J. B. 2021

  Abstract

  BACKGROUND: A Medicare effect has been described to account for increased health care utilization occurring at the age of 65 years. The existence of such an effect in cancer care, where it would be most likely to reduce mortality, has been unclear.METHODS: Patients aged 61 to 69 years who were diagnosed with lung, breast, colon, or prostate cancer from 2004 to 2016 were identified with the Surveillance, Epidemiology, and End Results database and were dichotomized on the basis of eligibility for Medicare (61-64 vs 65-69 years). With age-over-age (AoA) percent change calculations, trends in cancer diagnoses and staging were characterized. After matching, uninsured patients who were 61 to 64 years old (pre-Medicare group) were compared with insured patients who were 65 to 69 years old (post-Medicare group) with respect to cancer-specific mortality.RESULTS: In all, 134,991 patients were identified with lung cancer, 175,558 were identified with breast cancer, 62,721 were identified with colon cancer, and 238,823 were identified with prostate cancer. The AoA growth in the number of cancer diagnoses was highest at the age of 65 years in comparison with all other ages within the decade for all 4 cancers (P < .01, P < .001, P < .01, and P < .001, respectively). In a comparison of diagnoses at the age of 65 years with those in the 61- to 64-year-old cohort, the greatest difference for all 4 cancers was seen in stage I. In matched analyses, the 5-year cancer-specific mortality was worse for lung (86.3% vs 78.5%; P < .001), breast (32.7% vs 11.0%; P < .001), colon (57.1% vs 35.6%; P < .001), and prostate cancer (16.9% vs 4.8%; P < .001) in the uninsured pre-Medicare group than the insured post-Medicare group.CONCLUSIONS: The age threshold of 65 years for Medicare eligibility is associated with more cancer diagnoses (particularly stage I), and this results in lower long-term cancer-specific mortality for all cancers studied.LAY SUMMARY: Contributing to the current debate regarding Medicare for all, this study shows that the expansion of Medicare would improve cancer outcomes for the near elderly.

  View details for DOI 10.1002/cncr.33498

  View details for PubMedID 33778953

• Strong for Surgery: Association Between Bundled Risk Factors and Outcomes After Major Elective Surgery in the VA Population. World journal of surgery Liou, D. Z., Patel, D. C., Bhandari, P., Wren, S. M., Marshall, N. J., Harris, A. H., Shrager, J. B., Berry, M. F., Lui, N. S., Backhus, L. M. 2021

  Abstract

  BACKGROUND: Strong for Surgery (S4S) is a public health campaign focused on optimizing patient health prior to surgery by identifying evidence-based modifiable risk factors. The potential impact of S4S bundled risk factors on outcomes after major surgery has not been previously studied. This study tested the hypothesis that a higher number of S4S risk factors is associated with an escalating risk of complications and mortality after major elective surgery in the VA population.METHODS: The Veterans Affairs Surgical Quality Improvement Program (VASQIP) database was queried for patients who underwent major non-emergent general, thoracic, vascular, urologic, and orthopedic surgeries between the years 2008 and 2015. Patients with complete data pertaining to S4S risk factors, specifically preoperative smoking status, HbA1c level, and serum albumin level, were stratified by number of positive risk factors, and perioperative outcomes were compared.RESULTS: A total of 31,285 patients comprised the study group, with 16,630 (53.2%) patients having no S4S risk factors (S4S0), 12,323 (39.4%) having one (S4S1), 2,186 (7.0%) having two (S4S2), and 146 (0.5%) having three (S4S3). In the S4S1 group, 60.3% were actively smoking, 35.2% had HbA1c>7, and 4.4% had serum albumin<3. In the S4S2 group, 87.8% were smokers, 84.8% had HbA1c>7, and 27.4% had albumin<3. Major complications, reoperations, length of stay, and 30-day mortality increased progressively from S4S0 to S4S3 groups. S4S3 had the greatest adjusted mortality risk (adjusted odds radio [AOR] 2.56, p=0.04) followed by S4S2 (AOR 1.58, p=0.02) and S4S1 (AOR 1.34, p=0.02).CONCLUSION: In the VA population, patients who had all three S4S risk factors, namely active smoking, suboptimal nutritional status, and poor glycemic control, had the greatest risk of postoperative mortality compared to patients with fewer S4S risk factors.

  View details for DOI 10.1007/s00268-021-05979-8

  View details for PubMedID 33598723

• Estimating the Impact of Extended Delay to Surgery for Stage I Non-Small-Cell Lung Cancer on Survival: Lessons for the COVID-19 Pandemic. Annals of surgery Mayne, N. R., Elser, H., Darling, A. J., Raman, V., Liou, D., Colson, Y., D'Amico, T. A., Yang, C. J. 2021

  Abstract

  OBJECTIVE.: The purpose of this study is to evaluate the impact of extended delay to surgery for stage I non-small-cell lung cancer (NSCLC).SUMMARY BACKGROUND DATA.: During the COVID-19 pandemic, patients with NSCLC may experience delays in care, and some national guidelines recommend delays in surgery by >3 months for early NSCLC.METHODS.: Using data from the National Lung Screening Trial (NLST), a multi-center randomized trial, and the National Cancer Data Base (NCDB), a multi-institutional oncology registry, the impact of "early" versus "delayed" surgery (surgery received 0-30 versus 90-120 days following diagnosis) for stage I lung adenocarcinoma and squamous cell carcinoma was assessed using multivariable Cox regression analysis with penalized smoothing spline functions and propensity score-matched analyses.RESULTS.: In Cox regression analysis of the NLST (n = 452) and NCDB (n = 80,086) cohorts, an increase in the hazard ratio (HR) was seen the longer surgery was delayed. In propensity score-matched analysis, no differences in survival were found between early and delayed surgery for stage IA1 adenocarcinoma and IA1-IA3 squamous cell carcinoma (all P > 0.13). For stage IA2-IB adenocarcinoma and IB squamous cell carcinoma, delayed surgery was associated with worse survival (all P < 0.004).CONCLUSIONS.: The mortality risk associated with an extended delay to surgery differs across patient subgroups, and decisions to delay care during the COVID pandemic should take substage and histologic subtype into consideration. For stage IA1 adenocarcinoma and IA squamous cell carcinoma, delaying surgery may be considered; however, for IA2-IB adenocarcinoma and IB squamous cell carcinoma, early surgery-when feasible-should be encouraged.

  View details for DOI 10.1097/SLA.0000000000004811

  View details for PubMedID 33630435

• Use of a Personalized Multimedia Education Platform Improves Preoperative Teaching for Lung Cancer Patients. Seminars in thoracic and cardiovascular surgery Benson, J. n., Bhandari, P. n., Lui, N. n., Berry, M. n., Liou, D. Z., Shrager, J. n., Ayers, K. n., Backhus, L. M. 2021

  Abstract

  We sought to develop and evaluate a personalized multimedia education (ME) tool for pre-operative patient education to improve patient health knowledge, quality of life and satisfaction with care in thoracic surgery. The ME tool was developed and deployed in outpatient clinic during preoperative teaching for patients undergoing surgical resection for lung cancer for quality improvement. Patients were given an electronic survey prior to preoperative teaching and at initial post-operative visit to assess teaching effectiveness and care satisfaction. Sequential patients received either standard preoperative teaching or teaching using the ME tool. Pre- and postoperative survey responses were compared using independent sample paired t-test and multivariable linear regression modeling for adjustment. The final ME tool was an iPad application that incorporated real-time annotations of 3-dimensional, interactive anatomic diagrams. The tool featured video tours of operations, and radiology image import for annotation by the surgeon. Forty-eight patients were included in this pilot study (standard education (SE) n=26; ME, n=22). ME patients had significantly higher satisfaction scores compared to SE patients with respect to length of education materials, clarity of content, supportiveness of content and willingness to recommend materials to others. There was no difference in length of clinic visit between groups. Both patient and provider input can be used to create an innovative electronic preoperative educational tool that prepares and empowers patients in shared decision-making before surgery. Improvements in health literacy and self-efficacy may be more difficult to achieve but remain important as multimedia teaching tools are further developed.

  View details for DOI 10.1053/j.semtcvs.2021.03.003

  View details for PubMedID 33711462

• Perioperative Outcomes After Combined Esophagectomy and Lung Resection. The Journal of surgical research Patel, D. C., Bhandari, P., Shrager, J. B., Berry, M. F., Backhus, L. M., Lui, N. S., Liou, D. Z. 2021; 270: 413-420

  Abstract

  The impact of concomitant lung resection during esophagectomy on short-term outcomes is not well characterized. This study tests the hypothesis that lung resection at the time of esophagectomy is not associated with increased perioperative morbidity or mortality.Perioperative outcomes for esophageal cancer patients who underwent esophagectomy alone (EA) were compared to patients who had concurrent esophagectomy and lung resection (EL) using the NSQIP database between 2006-2017. Predictors of morbidity and mortality, including combined surgery, were evaluated using multivariable logistic regression.Among the 6,225 study patients, 6,068 (97.5%) underwent EA and 157 (2.5%) underwent EL. There were no differences in baseline characteristics between the two groups. Operating time for EL was longer than EA (median 416 versus 371 minutes, P < 0.01). Median length of stay was 10 d for both groups. Perioperative mortality was not significantly different between EL and EA patients (5.1% versus 2.8%, P = 0.08). EL patients had higher rates of postoperative pneumonia (22.3% versus 16.2%, P = 0.04) and sepsis (11.5% versus 7.1%, P = 0.03), however major complication rates overall were similar (40.8% versus 35.3%, P = 0.16). Combining lung resection with esophagectomy was not independently associated with increased postoperative morbidity (AOR 1.21 [95% CI 0.87-1.69]) or mortality (AOR 1.63 [95% CI 0.74-3.58]).Concurrent lung resection during esophagectomy is not associated with increased mortality or overall morbidity, but is associated with higher rates of pneumonia beyond esophagectomy alone. Surgeons considering combined lung resection with esophagectomy should carefully evaluate the patient's risk for pulmonary complications and pursue interventions preoperatively to optimize respiratory function.

  View details for DOI 10.1016/j.jss.2021.09.037

  View details for PubMedID 34775148

• First lung and kidney multi-organ transplant following COVID-19 Infection. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation Guenthart, B. A., Krishnan, A., Alassar, A., Madhok, J., Kakol, M., Miller, S., Cole, S. P., Rao, V. K., Acero, N. M., Hill, C. C., Cheung, C., Jackson, E. C., Feinstein, I., Tsai, A. H., Mooney, J. J., Pham, T., Elliott, I. A., Liou, D. Z., La Francesca, S., Shudo, Y., Hiesinger, W., MacArthur, J. W., Brar, N., Berry, G. J., McCarra, M. B., Desai, T. J., Dhillon, G. S., Woo, Y. J. 2021

  Abstract

  As the world responds to the global crisis of the COVID-19 pandemic an increasing number of patients are experiencing increased morbidity as a result of multi-organ involvement. Of these, a small proportion will progress to end-stage lung disease, become dialysis dependent, or both. Herein, we describe the first reported case of a successful combined lung and kidney transplantation in a patient with COVID-19. Lung transplantation, isolated or combined with other organs, is feasible and should be considered for select patients impacted by this deadly disease.

  View details for DOI 10.1016/j.healun.2021.02.015

  View details for PubMedID 34059432

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

  View details for DOI 10.1016/j.xjtc.2020.07.022

  View details for Web of Science ID 000655724800059

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

  View details for DOI 10.1016/j.xjtc.2020.07.022

  View details for PubMedID 34318000

  View details for PubMedCentralID PMC8303005

• Stereotactic Body Radiotherapy Versus Delayed Surgery for Early-stage Non-small-cell Lung Cancer. Annals of surgery Mayne, N. R., Lin, B. K., Darling, A. J., Raman, V., Patel, D. C., Liou, D. Z., D'Amico, T. A., Yang, C. J. 2020

  Abstract

  OBJECTIVE: To evaluate the overall survival of patients with operable stage IA non-small-cell lung cancer (NSCLC) who undergo "early" SBRT (within 0-30 days after diagnosis) versus "delayed" surgery (90-120 days after diagnosis).SUMMARY OF BACKGROUND DATA: During the COVID-19 pandemic, national guidelines have recommended patients with operable stage IA NSCLC to consider delaying surgery by at least 3 months or, alternatively, to undergo SBRT without delay. It is unknown which strategy is associated with better short- and long-term outcomes.METHODS: Multivariable Cox proportional hazards modeling and propensity score-matched analysis was used to compare the overall survival of patients with stage IA NSCLC in the National Cancer Data Base from 2004 to 2015 who underwent "early" SBRT (0-30 days after diagnosis) versus that of patients who underwent "delayed" wedge resection (90-120 days after diagnosis).RESULTS: During the study period, 570 (55%) patients underwent early SBRT and 475 (45%) underwent delayed wedge resection. In multivariable analysis, delayed resection was associated with improved survival [adjusted hazard ratio 0.61; 95% confidence interval (CI): 0.50-0.76]. Propensity-score matching was used to create 2 groups of 279 patients each who received early SBRT or delayed resection that were well-matched with regard to baseline characteristics. The 5-year survival associated with delayed resection was 53% (95% CI: 45%-61%) which was better than the 5-year survival associated with early SBRT (31% [95% CI: 24%-37%]).CONCLUSION: In this national analysis, for patients with stage IA NSCLC, extended delay of surgery was associated with improved survival when compared to early treatment with SBRT.

  View details for DOI 10.1097/SLA.0000000000004363

  View details for PubMedID 33074904

• Early Discharge Does Not Equate to Early Return for Patients Undergoing Lobectomy for Lung Cancer: A National Analysis Patel, D. C., Leipzig, M., Yang, C., Wang, Y., Shrager, J. B., Backhus, L. M., Lui, N. S., Liou, D. Z., Berry, M. F. ELSEVIER SCIENCE INC. 2020: S288

  View details for Web of Science ID 000582792300534

• Greater Ipsilateral Rectus Muscle Atrophy after Robotic Thoracic Surgery Compared to Open and VATS Approaches Wang, Y., Bhandari, P., Trope, W., Guenthart, B. A., Guo, H., Liou, D., Backhus, L. M., Berry, M., Ben Shrager, J., Lui, N. ELSEVIER SCIENCE INC. 2020: S289

  View details for Web of Science ID 000582792300536

• Commentary: Two decades of innovation, leadership, and overcoming challenges, but more lies ahead. The Journal of thoracic and cardiovascular surgery Liou, D. Z. 2020

  View details for DOI 10.1016/j.jtcvs.2020.09.080

  View details for PubMedID 33069423

• Cancer diagnoses and survival rise as 65-year-olds become Medicare eligible. Patel, D. C., He, H., Berry, M. F., Yang, C., Trope, W., Lui, N., Liou, D. Z., Backhus, L., Shrager, J. B. AMER SOC CLINICAL ONCOLOGY. 2020

  View details for Web of Science ID 000560368301130

• Sub-solid lung adenocarcinoma in Asian versus Caucasian patients: different biology but similar outcomes. Journal of thoracic disease Lui, N. S., Benson, J., He, H., Imielski, B. R., Kunder, C. A., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B. 2020; 12 (5): 2161-2171

  Abstract

  Asian and Caucasian patients with lung cancer have been compared in several database studies, with conflicting findings regarding survival. However, these studies did not include proportion of ground-glass opacity or mutational status in their analyses. Asian patients commonly develop sub-solid lung adenocarcinomas that harbor EGFR mutations, which have a better prognosis. We hypothesized that among patients undergoing surgery for sub-solid lung adenocarcinomas, Asian patients have better survival compared to Caucasian patients.We identified Asian and Caucasian patients who underwent surgical resection for a sub-solid lung adenocarcinoma from 2002 to 2015 at our institution. Sub-solid was defined as ≥10% ground-glass opacity on preoperative CT scan or ≥10% lepidic component on surgical pathology. Time-to-event multivariable analysis was performed to determine which characteristics were associated with recurrence and survival.Two hundred twenty-four patients were included with median follow up 48 months. Asian patients were more likely to be never smokers (76.3% vs. 29.0%, P<0.01) and have an EGFR mutation (69.4% vs. 25.6% of those tested, P<0.01), while Caucasian patients were more likely to have a KRAS mutation (23.5% vs. 4.9% of those tested, P<0.01). There was a trend towards Asian patients having a higher proportion of ground-glass opacity (38.8% vs. 30.5%, P=0.11). Time-to-event multivariable analysis showed that higher proportion of ground-glass opacity was significantly associated with better recurrence-free survival (HR 0.76 per 20% increase, P=0.02). However, mutational status and race did not have a significant impact on recurrence-free or overall survival.Asian and Caucasian patients with sub-solid lung adenocarcinoma have different tumor biology, but recurrence-free and overall survival after surgical resection is similar.

  View details for DOI 10.21037/jtd.2020.04.37

  View details for PubMedID 32642121

  View details for PubMedCentralID PMC7330405

• Sub-solid lung adenocarcinoma in Asian versus Caucasian patients: different biology but similar outcomes JOURNAL OF THORACIC DISEASE Lui, N. S., Benson, J., He, H., Imielski, B. R., Kunder, C. A., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B. 2020; 12 (5): 2161–71

  View details for DOI 10.21037/jtd.2020.04.37

  View details for Web of Science ID 000537461900045

• A National Analysis of Treatment Patterns and Outcomes for Patients 80 Years or Older with Esophageal Cancer. Seminars in thoracic and cardiovascular surgery Yang, C. J., Wang, Y. n., Raman, V. n., Patel, D. n., Lui, N. n., Backhus, L. n., Shrager, J. n., Berry, M. F., Liou, D. n. 2020

  Abstract

  The purpose of this study was to evaluate practice patterns and outcomes for patients 80 years or older with esophageal cancer using a nationwide cancer database. Practice patterns for patients 80 years or older with stage I-IV esophageal cancer in the National Cancer Database from 2004-2014 were analyzed. Overall survival associated with different treatment strategies were evaluated using the Kaplan-Meier method and multivariable Cox proportional hazard models. In the study period, 40.5% and 46.2% of patients with stage I adenocarcinoma and squamous cell carcinoma, respectively, did not receive any treatment at all. Less than 11% (196/1,865) of patients with stage I-II disease underwent esophagectomy, even though surgery was associated with a better 5-year survival compared to no treatment (stage I: 47.3% [95% CI 36.2%-57.6%] vs 14.9% [95% CI: 11.2%-19.1%]; stage II: 29.3% [95% CI 20.1%-39.1%] vs 1.2% [95% CI: 0.1%-5.5%]). Of the 1,596 (37.7%) patients with stage III disease who received curative-intent treatment (surgery or chemoradiation), the 5-year survival was significantly better than that of patients who received no treatment (11.9% [95% CI: 9.7%-14.4% vs 4.3% [95% CI: 1.9%-8.3%]). In this national analysis of patients 80 years and older with esophageal cancer, over 40% of patients with stage I disease did not receive treatment. Patients with stage I-III disease had better survival and risks and benefits of treatment for elderly patients should be discussed in a multidisciplinary setting.

  View details for DOI 10.1053/j.semtcvs.2020.09.004

  View details for PubMedID 32977014

• Does size matter? A national analysis of the utility of induction therapy for large thymomas. Journal of thoracic disease Liou, D. Z., Ramakrishnan, D. n., Lui, N. S., Shrager, J. B., Backhus, L. M., Berry, M. F. 2020; 12 (4): 1329–41

  Abstract

  Tumor size of 8 cm or greater is a risk factor for recurrence after thymoma resection, but the role of induction therapy for large thymomas is not well defined. This study tested the hypothesis that induction therapy for thymomas 8 cm and larger improves survival.The use of induction therapy for patients treated with surgical resection for Masaoka stage I-III thymomas in the National Cancer Database between 2006-2013 was evaluated using logistic regression, Kaplan-Meier analysis, and Cox-proportional hazards methods.Of the 1,849 patients who met inclusion criteria, 582 (31.5%) had tumors ≥8 cm. Five-year survival was worse in patients with tumors ≥8 cm compared to smaller tumors [84.6% (95% CI: 81.2-88.1%) vs. 89.4% (95% CI: 87.2-91.7%), P=0.003]. Induction therapy was used in 166 (9.0%) patients overall and was more likely in patients with tumors ≥8 cm [adjusted odds ratio (AOR) 3.257, P<0.001]. Induction therapy was not associated with improved survival in the subset of patients with tumors ≥8 cm in either univariate [80.9% (95% CI: 72.6-90.1%) vs. 85.4% (95% CI: 81.8-89.3%), P=0.27] or multivariable analysis [hazard ratio (HR) 1.54, P=0.10]. Increasing age (HR 1.56/decade, P<0.001) and Masaoka stage III (HR 1.76, P=0.04) were associated with worse survival in patients with tumors ≥8 cm.Survival after thymoma resection is worse for tumors 8 cm or larger compared to smaller tumors and is not improved by induction therapy. Size alone should not be a criterion for using induction therapy prior to thymoma resection.

  View details for DOI 10.21037/jtd.2020.02.63

  View details for PubMedID 32395270

  View details for PubMedCentralID PMC7212162

• Paradoxical Motion on Sniff Test Predicts Greater Improvement Following Diaphragm Plication. The Annals of thoracic surgery Patel, D. C., Berry, M. F., Bhandari, P. n., Backhus, L. M., Raees, S. n., Trope, W. n., Nash, A. n., Lui, N. S., Liou, D. Z., Shrager, J. B. 2020

  Abstract

  Diaphragm plication (DP) improves pulmonary function and quality of life for those with diaphragm paralysis/dysfunction. It is unknown whether differing degrees of diaphragm dysfunction as measured by sniff testing impact results after plication.Patients who underwent minimally invasive DP from 2008-2019 were dichotomized based on sniff test results: paradoxical motion (PM) vs. no paradoxical motion (NPM) - the latter including normal/decreased/no motion. Preoperative and postoperative pulmonary function testing (PFT) after DP was compared between the two groups. The impact of diaphragm height index (DHI), a measure of diaphragm elevation, was also assessed.Twenty-six patients underwent preoperative sniff testing, DP, and postoperative PFTs. Including all patients, DP resulted in a 17.8 ± 5.5% (p<0.001) improvement in forced expiratory volume at 1 second (FEV1), a 14.4 ± 5.3% (p<0.001) improvement in forced vital capacity (FVC), and a 4.7 ± 4.6% (p=0.539) improvement in diffusing capacity (DLCO). There were greater improvements in the PM group (n=16) vs. NPM group (n=10) for FEV1 (27.2 ± 6.0% vs. 3.9 ± 6.2%, p=0.017) and FVC (28.1 ± 5.3% vs. -0.5 ± 3.3%, p=0.001). There was no difference in ΔDLCO between groups. There were no differences between patients with PM and NPM in postoperative course/complications. No value for DHI predicted improvement in PFTs following DP.Patients with PM on sniff test have dramatically greater objective improvements in pulmonary function following plication than those without PM. Most patients without PM do not demonstrate improvement in standard PFTs. Improvements in dyspnea require additional study.

  View details for DOI 10.1016/j.athoracsur.2020.07.049

  View details for PubMedID 33031777

• National Evaluation of Short-Term and Intermediate-Term Readmission after Esophagectomy Yang, C. J., Wang, Y., He, H., Liou, D., Lui, N., Berry, M. F., Shrager, J., Backhus, L. ELSEVIER SCIENCE INC. 2019: S279–S280

  View details for Web of Science ID 000492740900545

• Management of Benign Esophageal Perforation in the National Inpatient Sample Lui, N., Bhandari, P., Backhus, L., Liou, D., Shrager, J., Berry, M. F. ELSEVIER SCIENCE INC. 2019: E209

  View details for Web of Science ID 000492749600500

• The influence of hormone replacement therapy on lung cancer incidence and mortality. The Journal of thoracic and cardiovascular surgery Titan, A. L., He, H. n., Lui, N. n., Liou, D. n., Berry, M. n., Shrager, J. B., Backhus, L. M. 2019

  Abstract

  Data regarding the effects of hormone replacement therapy (HRT) on non-small cell lung cancer (NSCLC) are mixed. We hypothesized HRT would have a protective benefit with reduced NSCLC incidence among women in a large, prospective cohort.We used data from the multicenter randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (1993-2001). Participants were women aged 50 to 74 years followed prospectively for up to 13 years for cancer screening. The influence of HRT on the primary outcome of NSCLC incidence and secondary outcomes of all-cause and disease-specific mortality were assessed with Kaplan-Meier analysis and Cox proportional hazard models adjusting for covariates.In the overall cohort of 75,587 women, 1147 women developed NSCLC after a median follow-up of 11.5 years. HRT use was characterized as 49.4% current users, 17.0% former users, and 33.6% never users. Increased age, smoking, comorbidities, and family history were associated with increased risk of NSCLC. On multivariable analysis, current HRT use was associated with reduced risk of NSCLC compared with never users (hazard ratio, 0.80; 95% confidence interval, 0.70-0.93; P = .009). HRT or oral contraception use was not associated with significant differences in all-cause mortality or disease-specific mortality.These data represent among the largest prospective cohorts suggesting HRT use may have a protective effect on the development of NSCLC among women; the physiological basis of this effect merits further study; however, the results may influence discussion surrounding HRT use in women.

  View details for DOI 10.1016/j.jtcvs.2019.10.070

  View details for PubMedID 31866083

• A national analysis of open versus minimally invasive thymectomy for stage I to III thymoma. The Journal of thoracic and cardiovascular surgery Yang, C. J., Hurd, J. n., Shah, S. A., Liou, D. n., Wang, H. n., Backhus, L. M., Lui, N. S., D'Amico, T. A., Shrager, J. B., Berry, M. F. 2019

  Abstract

  The oncologic efficacy of minimally invasive thymectomy for thymoma is not well characterized. We compared short-term outcomes and overall survival between open and minimally invasive (video-assisted thoracoscopic and robotic) approaches using the National Cancer Data Base.Perioperative outcomes and survival of patients who underwent open versus minimally invasive thymectomy for clinical stage I to III thymoma from 2010 to 2014 in the National Cancer Data Base were evaluated using multivariable Cox proportional hazards modeling and propensity score-matched analysis. Predictors of minimally invasive use were evaluated using multivariable logistic regression. Outcomes of surgical approach were evaluated using an intent-to-treat analysis.Of the 1223 thymectomies that were evaluated, 317 (26%) were performed minimally invasively (141 video-assisted thoracoscopic and 176 robotic). The minimally invasive group had a shorter median length of stay when compared with the open group (3 [2-4] days vs 4 [3-6] days, P < .001). In a propensity score-matched analysis of 185 open and 185 minimally invasive (video-assisted thoracoscopic + robotic) thymectomy, the minimally invasive group continued to have a shorter median length of stay (3 vs 4 days, P < .01) but did not have significant differences in margin positivity (P = .84), 30-day readmission (P = .28), 30-day mortality (P = .60), and 5-year survival (89.4% vs 81.6%, P = .20) when compared with the open group.In this national analysis, minimally invasive thymectomy was associated with shorter length of stay and was not associated with increased margin positivity, perioperative mortality, 30-day readmission rate, or reduced overall survival when compared with open thymectomy.

  View details for DOI 10.1016/j.jtcvs.2019.11.114

  View details for PubMedID 32245668

• Induction therapy for locally advanced distal esophageal adenocarcinoma: Is radiation Always necessary? Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. MOSBY-ELSEVIER. 2018: 2697–2705

  View details for DOI 10.1016/j.jtcvs.2017.12.136

  View details for Web of Science ID 000432369400117

• Induction therapy for locally advanced distal esophageal adenocarcinoma: Is radiation Always necessary? The Journal of thoracic and cardiovascular surgery Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2018

  Abstract

  OBJECTIVE: To compare outcomes between induction chemotherapy alone (ICA) and induction chemoradiation (ICR) in patients with locally advanced distal esophageal adenocarcinoma.METHODS: Patients in the National Cancer Database treated with ICA or ICR followed by esophagectomy between 2006 and 2012 for cT1-3N1M0 or T3N0M0 adenocarcinoma of the distal esophagus were compared using logistic regression, Kaplan-Meier analysis, and Cox proportional hazards methods.RESULTS: The study group included 4763 patients, of whom 4323 patients (90.8%) received ICR and 440 patients (9.2%) received ICA. There were no differences in age, sex, race, Charlson Comorbidity Index, treatment facility type, clinical T or N status between the 2 groups. Tumor size ≥5cm (odds ratio, 1.46; P=.006) was the only factor that predicted ICR use. Higher rates of T downstaging (39.7% vs 33.4%; P=.012), N downstaging (32.0% vs 23.4%; P<.001), and complete pathologic response (13.1% vs 5.9%; P<.001) occurred in ICR patients. Positive margins were seen more often in ICA patients (9.6% vs 5.5%; P=.001), but there was no difference in 5-year survival (ICR 35.9% vs ICA 37.2%; P=.33), and ICR was not associated with survival in multivariable analysis (hazard ratio=1.04; P=.61).CONCLUSIONS: ICR for locally advanced distal esophageal adenocarcinoma is associated with a better local treatment effect, but not improved survival compared with ICA, which suggests that radiation can be used selectively in this clinical situation.

  View details for PubMedID 29530567

• Thoracic Surgery Considerations in Obese Patients THORACIC SURGERY CLINICS Liou, D. Z., Berry, M. F. 2018; 28 (1): 27-+

  Abstract

  The obesity epidemic in the United States has increased greatly over the past several decades, and thoracic surgeons are likely to see obese patients routinely in their practices. Obesity has direct deleterious health effects such as metabolic disorder and cardiovascular disease, and is associated with many cancers. Obese patients who need thoracic surgery pose practical challenges to many of the routine elements in perioperative management. Preoperative assessment of obesity-related comorbid conditions and risk stratification for surgery, thorough intraoperative planning for anesthesia and surgery, and postoperative strategies to optimize pulmonary hygiene and mobility minimize the risk of adverse outcomes.

  View details for PubMedID 29150035

• Predictors of Failure to Rescue After Esophagectomy. Ann Thorac Surg. Liou, D. Z., Serna-Gallegos, D., Mirocha, J., Bairamian, V., Alban, R. F., Soukiasian, H. J. 2018; 105 (3): 871-878
• Survival Difference in Patients with Malignant Pleural Effusions Treated with Pleural Catheter or Talc Pleurodesis. The American surgeon Liou, D. Z., Serna-Gallegos, D., Chan, J. L., Borgella, J., Akhmerov, S., Soukiasian, H. J. 2016; 82 (10): 995-999

  Abstract

  Malignant pleural effusions (MPE) are commonly managed with either pleural catheter (PC) or talc pleurodesis (TP). The aim of this study was to compare survival in MPE patients treated with either PC or TP. A retrospective review of our cancer center database was performed. Patients with metastatic cancer and MPE were analyzed. Demographic and clinical data were tabulated and compared. A total of 238 patients with MPE treated by either PC or TP were included. Of these, 79 patients comprised the PC group and 159 the TP group. PC had a higher incidence of advanced disease (stage III or IV) at initial diagnosis compared with TP (70.9% vs 57.2%, P = 0.05). TP had a longer postprocedure length of stay compared with PC (7.1 vs 5.0 days, P = 0.02); however, overall length of stay was similar (9.7 vs 11.1 days, P = 0.34). Readmissions were significantly lower in TP (11.9% vs 22.8%, P = 0.04). Mean survival was higher in TP compared with PC (18.7 vs 4.1 months, P < 0.001). Patients with metastatic cancer and MPE treated with TP had significantly higher survival compared with PC. This is likely related to a greater disease burden in PC, as 70 per cent of patients in this group had stage III or IV disease on initial presentation.

  View details for PubMedID 27779992

• Thromboelastography After Murine TBI and Implications of Beta-Adrenergic Receptor Knockout. Neurocritical care Liou, D. Z., Ko, A., Volod, O., Barmparas, G., Harada, M. Y., Martin, M. J., Salim, A., Dhillon, N., Thomsen, G. M., Ley, E. J. 2016; 25 (1): 145-52

  Abstract

  The source of coagulopathy in traumatic brain injury (TBI) is multifactorial and may include adrenergic stimulation. The aim of this study was to assess coagulopathy after TBI using thromboelastography (TEG), and to investigate the implications of β-adrenergic receptor knockout.Adult male wild type c57/bl6 (WT) and β1/β2-adrenergic receptor knockout (BKO) mice were assigned to either TBI (WT-TBI, BKO-TBI) or sham injury (WT-sham, BKO-sham). Mice assigned to TBI were subject to controlled cortical impact (CCI). At 24 h post-injury, whole blood samples were obtained and taken immediately for TEG.At 24 h after injury, a trend toward increased fibrinolysis was seen in WT-TBI compared to WT-sham although this did not reach significance (EPL 8.1 vs. 0 %, p = 0.18). No differences were noted in fibrinolysis in BKO-TBI compared to BKO-sham (LY30 2.6 vs. 2.5 %, p = 0.61; EPL 3.4 vs. 2.9 %, p = 0.61). In addition BKO-TBI demonstrated increased clot strength compared to BKO-sham (MA 76.6 vs. 68.6, p = 0.03; G 18.2 vs. 11.3, p = 0.03).In a mouse TBI model, WT mice sustaining TBI demonstrated a trend toward increased fibrinolysis at 24 h after injury while BKO mice did not. These findings suggest β-blockade may attenuate the coagulopathy of TBI and minimize progression of intracranial hemorrhage by reducing fibrinolysis and increasing clot strength.

  View details for DOI 10.1007/s12028-015-0223-9

  View details for PubMedID 26666545

• Insulin-dependent diabetes and serious trauma. European journal of trauma and emergency surgery : official publication of the European Trauma Society Liou, D. Z., Singer, M. B., Barmparas, G., Harada, M. Y., Mirocha, J., Bukur, M., Salim, A., Ley, E. J. 2016; 42 (4): 491-6

  Abstract

  Trauma patients with diabetes mellitus (DM) represent a unique population as the acute injury and the underlying disease may both cause hyperglycemia that leads to poor outcomes. We investigated how insulin-dependent DM (IDDM) and noninsulin-dependent DM (NIDDM) impact mortality after serious trauma without brain injury.The National Trauma Data Bank (NTDB) version 7.0 was queried for all patients with moderate to severe traumatic injury [injury severity score (ISS) >9]. Patients were excluded if missing data, age <10 years, severe brain injury [head abbreviated injury scale (AIS) >3], dead on arrival or any AIS = 6. Logistic regression modeled the association between DM and mortality as well as IDDM, NIDDM and mortality.Overall 166,103 trauma patients without brain injury were analyzed. Mortality was 7.6 and 4.4 % in patients with and without DM, respectively (p < 0.01). Mortality was 9.9 % for patients with IDDM and 6.7 % for NIDDM (p < 0.01). The increased mortality associated with DM was only significantly higher for DM patients in their forties (5.6 vs. 3.3 %, p < 0.01). Regression analyses demonstrated that DM (AOR 1.14, p = 0.04) and IDDM (AOR 1.46, p < 0.01) were predictors of mortality compared to no DM, but NIDDM was not (AOR 1.02, p = 0.83).While DM was a predictor for higher mortality after serious trauma, this increase was only observed in IDDM and not NIDDM. Our findings suggest IDDM patients who present after serious trauma are unique and attention to their hyperglycemia and related insulin therapy may play a critical role in recovery.

  View details for DOI 10.1007/s00068-015-0561-5

  View details for PubMedID 26253885

• Recovery of Native Renal Function in Patients with Hepatorenal Syndrome Following Combined Liver and Kidney Transplant with Mercaptoacetyltriglycine-3 Renogram: Developing a Methodology World journal of nuclear medicine Aparici, C. M., Bains, S. N., Qian, L., Liou, D., Wojciechowski, D., Werner, J., Khan, S., Kroll, C., Sandhu, M., Nguyen, N., Hawkins, R. 2016; 15 (1)
• Bicycle trauma and alcohol intoxication INTERNATIONAL JOURNAL OF SURGERY Harada, M. Y., Gangi, A., Ko, A., Liou, D. Z., Barmparas, G., Li, T., Hotz, H., Stewart, D., Ley, E. J. 2015; 24: 14–19

  Abstract

  As bicycling has become more popular, admissions after bicycle trauma are on the rise. The impact of alcohol use on bicycle trauma has not been well studied. The aim of this study was to examine the effect of alcohol intoxication on injury burden following bicycle-related crashes.A retrospective review of trauma patients presenting to a Level I trauma center after bicycle-related crashes from January 2002 to December 2011 was conducted. Demographics, injury data, alcohol intoxication, helmet use, and clinical outcomes were reviewed. Blood alcohol level (BAL) was considered positive if >0.01 g/dL. Variables were compared between patients based on BAL: negative, 0.01-0.16 g/dL, and >0.16 g/dL.During the 10 year study period, 563 patients met study criteria; mean age was 33.5 ± 16.5 years, 87% were male, and mortality was 1%. On average, bicycle crashes increased over the study period by 4.4 collisions per year. BAL was tested in 211 (38%) patients. Mean BAL was 0.24 g/dL, with 37% of these patients being intoxicated (BAL ≥ 0.010 g/dL). Intoxicated patients were significantly less likely to wear a helmet (4.7% vs. 22.2%, p = 0.002) and to be involved in motor vehicle crash (59.0% vs. 81.2%, p < 0.001). There was no difference noted in the injury burden including ISS ≥ 16 (14.3% vs. 19.5%, p = 0.335) and AIS Head ≥ 3 (17.9% vs. 21.8%, p = 0.502). When comparing patients according to their BAL, there was a decreasing risk of motor vehicle collision with increasing BAL (81.2% for undetected, 76.5% for BAL ≤ 0.16 g/dL and 54.1% for BAL >0.16 g/dL, p < 0.001). The risk for a severe head injury (AIS Head ≥ 3) was significantly lower in helmeted patients (8.4% vs. 15.8%, p = 0.035).The incidence of bicycle-related crashes is increasing and more than a third of patients tested for alcohol after bicycle-related crashes are found to be intoxicated. The injury burden in intoxicated patients, including head trauma, was not different compared to non-intoxicated patients. In addition, the risk for a collision with a motor vehicle was significantly lower. Nonetheless, these patients rarely utilize a helmet. The findings from this study can be used for the development and implementation of preventive strategies to minimize the injury burden associated with bicycle crashes and intoxicated cyclists.

  View details for DOI 10.1016/j.ijsu.2015.10.013

  View details for Web of Science ID 000366662600004

  View details for PubMedID 26493212

• Work Hour Reduction: Still Room for Improvement. Journal of surgical education Liou, D. Z., Barmparas, G., Harada, M., Chung, R., Melo, N., Ley, E. J., Salim, A., Bukur, M. 2015; 73 (1): 173-9

  Abstract

  The effect of resident duty hour restrictions continues to yield conflicting results on patient outcomes. Failure to rescue (FTR), or death after a major complication, has become a topic of increasing quality assessment. The aim of this study is to evaluate the effect of duty hour restrictions on in-hospital mortality, complication rates, and FTR in patients suffering traumatic injuries.Data from the National Trauma Data Bank (NTDB) were retrospectively reviewed (Research Data Set 2007-2008 and version 7.2). Patients admitted to Level I or II teaching institutions were dichotomized into pre-duty hour restriction (2002-2003) and post-duty hour restriction (2007-2008) time periods. Patients who had nonsurvivable injuries (any region Abbreviated Injury Scale score = 6), died within 48 hours, or had missing data were excluded. Multivariate logistic regression was used to adjust for differences in patient characteristics and derive adjusted outcomes.Level I and II teaching institutions in the NTDB.All patients with trauma admitted to a Level I or II teaching institution between January 1, 2002 and June 30, 2003 and between January 1, 2007 and December 31, 2008.Although overall adjusted in-hospital mortality was decreased (adjusted odds ratio [AOR] = 0.7, p < 0.001) in the post-duty hour restriction era, overall complications (AOR = 2.0, p < 0.001) and FTR (AOR = 2.0, p < 0.001) were significantly higher.Although there may be some benefit to resident duty hour restrictions, there is still room for improvement in patient care. Individual institutions should carefully review their own complication data to identify preventable systems issues, such as poor handoffs, and opportunities for increased resident supervision.

  View details for DOI 10.1016/j.jsurg.2015.07.016

  View details for PubMedID 26319104

• Alcohol intoxication may be associated with reduced truncal injuries after blunt trauma. American journal of surgery Liou, D. Z., Barmparas, G., Zaw, A., Bukur, M., Salim, A., Ley, E. J. 2015; 210 (1): 87-92

  Abstract

  Prior studies suggest that positive blood alcohol concentration (BAC) is associated with lower mortality after motor vehicle collisions (MVCs). We investigated the relationship between increasing BAC and mortality after MVC.A retrospective review of the Los Angeles County trauma database from January 2003 to December 2008 was performed. MVC patients greater than or equal to 16 years of age with admission BAC were considered. Patients were stratified by BAC as follows: BAC0 (<.01), BAC1 (.01 to .08), BAC2 (.09 to .16), BAC3 (.17 to .24), BAC4 (.25 to .32), and BAC5 (>.32). Logistic regression was used to determine predictors of mortality.A total of 12,540 patients were included. Overall mortality rate was 2.2%. Mortality was lowest in BAC3 (1.6%) and BAC4 (1.3%), although the difference among all groups was not statistically significant (P = .07). Decreased rates of Injury Severity Score greater than or equal to 16 were noted with increasing BAC, which was largely because of reduced chest and abdomen/pelvis Abbreviated Injury Scale. Adjusted mortality was lower in BAC3 and BAC4 (both adjusted odds ratio .4, P < .001).A protective effect of alcohol after MVC may be related to decreased truncal injury burden rather than protection after head injury.

  View details for DOI 10.1016/j.amjsurg.2014.11.015

  View details for PubMedID 25921093

• Impact of body mass index on injury in abdominal stab wounds: implications for management. The Journal of surgical research Bloom, M. B., Ley, E. J., Liou, D. Z., Tran, T., Chung, R., Melo, N., Margulies, D. R. 2015; 197 (1): 162-6

  Abstract

  Although it is assumed that obese patients are naturally protected against anterior abdominal stab wounds, the relationship has never been formally studied. We sought to examine the impact of body mass index (BMI) on severity of sustained injury, need for operation, and patient outcomes.We conducted a review of all patients presenting with abdominal stab wounds at an urban level I trauma center from January 2000-December 2012. Patients were divided into groups based on their BMI (<18.5, 18.5-29.9, 30-35, and >35). Data abstracted included baseline demographics, physiologic data, and characterization of whether the stab wound had violated the peritoneum, caused intra-abdominal injury, or required an operation that was therapeutic. The one-sided Cochran-Armitage trend test was used for significance testing of the protective effect.Of 281 patients with abdominal stab wounds, 249 had complete data for evaluation. Chest and abdomen abbreviated injury scale trends decreased with increasing BMI, as did overall injury severity score, the percent of patients severely injured (injury severity score ≥ 25), and length of intensive care unit stay. Rates of peritoneal violation (100%, 84%, 77%, and 74%; P = 0.077), visceral injury (83%, 56%, 50%, and 30%; P = 0.022), and injury requiring a therapeutic operation (67%, 45%, 40%, and 20%; P = 0.034) all decreased with increasing BMI. Patients in the thinnest group required an operation three times more often than those in the most obese.Increased BMI protects patients with abdominal stab wounds and is associated with lower incidence of severe injury and need for operation. Heavier patients may be more suitable to observation and serial examinations, whereas very thin patients are more likely to require an operation and be critically injured.

  View details for DOI 10.1016/j.jss.2015.03.052

  View details for PubMedID 25891677

• Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma Multi-Institutional Trials Group Study. The journal of trauma and acute care surgery Inaba, K., Nosanov, L., Menaker, J., Bosarge, P., Williams, L., Turay, D., Cachecho, R., de Moya, M., Bukur, M., Carl, J., Kobayashi, L., Kaminski, S., Beekley, A., Gomez, M., Skiada, D. 2015; 78 (3): 459-65; discussion 465-7

  Abstract

  Unlike the cervical spine (C-spine), where National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rules can be used, evidence-based thoracolumbar spine (TL-spine) clearance guidelines do not exist. The aim of this study was to develop a clinical decision rule for evaluating the TL-spine after injury.Adult (≥15 years) blunt trauma patients were prospectively enrolled at 13 US trauma centers (January 2012 to January 2014). Exclusion criteria included the following: C-spine injury with neurologic deficit, preexisting paraplegia/tetraplegia, and unevaluable examination. Remaining evaluable patients underwent TL-spine imaging and were followed up to discharge. The primary end point was a clinically significant TL-spine injury requiring TL-spine orthoses or surgical stabilization. Regression techniques were used to develop a clinical decision rule. Decision rule performance in identifying clinically significant fractures was tested.Of 12,479 patients screened, 3,065 (24.6%) met inclusion criteria (mean [SD] age, 43.5 [19.8] years [range, 15-103 years]; male sex, 66.3%; mean [SD] Injury Severity Score [ISS], 8.8 [7.5]). The majority underwent computed tomography (93.3%), 6.3% only plain films, and 0.2% magnetic resonance imaging exclusively. TL-spine injury was identified in 499 patients (16.3%), of which 264 (8.6%) were clinically significant (29.2% surgery, 70.8% TL-spine orthosis). The majority was AO Type A1 282 (56.5%), followed by 67 (13.4%) A3, 43 (8.6%) B2, and 32 (6.4%) A4 injuries. The predictive ability of clinical examination (pain, midline tenderness, deformity, neurologic deficit), age, and mechanism was examined; positive clinical examination finding resulted in a sensitivity of 78.4% and a specificity of 72.9%. Addition of age of 60 years or older and high-risk mechanism (fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian) increased sensitivity to 98.9% with specificity of 29.0% for clinically significant injuries and 100.0% sensitivity and 27.3% specificity for injuries requiring surgery.Clinical examination alone is insufficient for determining the need for imaging in evaluable patients at risk of TL-spine injury. Addition of age and high-risk mechanism results in a clinical decision-making rule with a sensitivity of 98.9% for clinically significant injuries.Diagnostic test, level III.

  View details for DOI 10.1097/TA.0000000000000560

  View details for PubMedID 25710414

• Impact of positive fluid balance on critically ill surgical patients: a prospective observational study. Journal of critical care Barmparas, G., Liou, D., Lee, D., Fierro, N., Bloom, M., Ley, E., Salim, A., Bukur, M. 2014; 29 (6): 936-41

  Abstract

  The purpose of this study is to determine the effect of postoperative fluid balance (FB) on subsequent outcomes in acute care surgery (ACS) patients admitted to the surgical intensive care unit (ICU).Acute care surgery patients admitted to the surgical ICU from 06/2012 to 01/2013 were followed up prospectively. Patients were stratified by FB into FB-positive (+) and FB-negative (-) groups by surgical ICU day 5 or day of discharge from the surgical ICU.A total of 144 ACS patients met inclusion criteria. Although there was no statistically significant difference in crude mortality (11% for FB [-] vs 15.5% for FB [+]; P=.422], after adjusting for confounding factors, achieving an FB (-) status by day 5 during the surgical ICU stay was associated with an almost 70% survival benefit (adjusted odds ratio [95% confidence interval], 0.31 [0.13, 0.76]; P=.010). In addition, achieving a fluid negative status by day 1 provided a protective effect for both overall and infectious complications (adjusted odds ratio [95% confidence interval], 0.63 [0.45, 0.88]; P=.006 and 0.64 [0.46, 0.90]; P=.010, respectively).In a cohort of critically ill ACS patients, achieving FB (-) status early during surgical ICU admission was associated with a nearly 70% reduction in the risk for mortality.

  View details for DOI 10.1016/j.jcrc.2014.06.023

  View details for PubMedID 25085510

• Prehospital hypertension is predictive of traumatic brain injury and is associated with higher mortality. The journal of trauma and acute care surgery Barmparas, G., Liou, D. Z., Lamb, A. W., Gangi, A., Chin, M., Ley, E. J., Salim, A., Bukur, M. 2014; 77 (4): 592-8

  Abstract

  The purpose of the current study was to investigate the effect of early adrenergic hyperactivity as manifested by prehospital (emergency medical service [EMS]) hypertension on outcomes of traumatic brain injury (TBI) patients and to develop a prognostic model of the presence of TBI based on EMS and admission (emergency department [ED]) hypertension.This study is a retrospective review of the 2007 to 2008 National Trauma Data Bank including blunt trauma patients 15 years or older with available EMS and ED vital signs. Patients with head Abbreviated Injury Scale (AIS) score of 3 or greater were selected, and mortality was examined within EMS systolic blood pressure (SBP) groups: lower than 100 mm Hg, 110 mm Hg to 150 mm Hg, 160 mm Hg to 180 mm Hg, and 190 mm Hg to 230 mm Hg. A forward logistic regression model including the EMS heart rate, EMS SBP, EMS Glasgow Coma Scale (GCS) score, ED heart rate, and ED SBP was used to identify predictors of a TBI in patients with ED GCS score of less than or equal to 8, 9 to 13, and 14 to 15.For the 5-year study period, 315,242 patients met inclusion criteria. Adjusted odds for mortality increased in a stepwise fashion with increasing EMS SBP compared with patients with normal EMS SBP (adjusted odds ratio [95% confidence interval], 1.33 [1.22-1.44], p < 0.001, for EMS SBP of 160-180 mm Hg and 1.97 [1.76-2.21], p < 0.001, for EMS SBP of 190-230 mm Hg). A 7-point scoring system was developed for each ED GCS score group to predict the presence of a TBI. EMS SBP of greater than 150 mm Hg and ED SBP of greater than 150 mm Hg were both predictive of the presence of a TBI in patients with ED GCS score of 8 or less and in patients with ED GCS score of 9 to 13 or 14 to 15, respectively.Prehospital hypertension in TBI is associated with a higher mortality risk. Early hypertension in the prehospital setting and at admission can be used to predict the presence of such injuries. These findings may have important early triage and treatment implications.Prognostic study, level III.

  View details for DOI 10.1097/TA.0000000000000382

  View details for PubMedID 25250599

• Defining early trauma-induced coagulopathy using thromboelastography. The American surgeon Liou, D. Z., Shafi, H., Bloom, M. B., Chung, R., Ley, E. J., Salim, A., Tcherniantchouk, O., Margulies, D. R. 2014; 80 (10): 994-8

  Abstract

  Early trauma-induced coagulopathy (ETIC) is abnormal coagulation detected on presentation, but a clear description is lacking. We used thromboelastography (TEG) to characterize ETIC. Data were prospectively collected on high-acuity trauma activations at an urban Level I trauma center between July 2012 and May 2013. Patients with admission TEG before any blood transfusion were stratified by Injury Severity Score (ISS): mild (less than 16), moderate (16 to 24), severe (25 or greater). TEG parameters were compared between groups. ETIC was defined as any abnormality detected on TEG. Fifty-two patients were included; mean age was 49 years and mean time to the emergency department was 26 minutes. Mean ISS for the cohort was 17 with 28 patients in mild, eight in moderate, and 16 in severe. Glasgow Coma Score was lower and head Abbreviated Injury Scale was higher in severe (P < 0.001). Forty-three (83%) patients had an abnormal TEG. Shortened reaction (R) time was noted in 42 patients. There were no differences in any TEG parameters between the injury severity groups. Hyperfibrinolysis was detected in four (8%) patients. ETIC was present in over 80 per cent of high-acuity trauma activations irrespective of injury severity and characterized primarily by shortened R time, indicating ETIC is initially described by a hypercoagulable state as a result of thrombin generation.

  View details for PubMedID 25264646

• To swab or not to swab? A prospective analysis of 341 SICU VRE screens. The journal of trauma and acute care surgery Liou, D. Z., Barmparas, G., Ley, E. J., Salim, A., Tareen, A., Casas, T., Lee, D., Bukur, M. 2014; 76 (5): 1192-200

  Abstract

  Vancomycin-resistant Enterococcus (VRE) screening is routine practice in many intensive care units despite the question of its clinical significance. The value of VRE screening at predicting subsequent VRE or other hospital-acquired infection (HAI) is unknown. The purpose of this investigation was to examine the rate of subsequent VRE HAI in patients undergoing VRE screening.This study was conducted in a 24-bed surgical intensive care unit (SICU) at a Level I trauma center. Patients admitted to the SICU between February and August 2011 who had rectal swab for VRE screening within 72 hours were followed prospectively for the development of VRE and other HAIs. Demographics, clinical characteristics, and infection rates were compared between VRE-positive and VRE-negative patients. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VRE screening for predicting subsequent VRE HAI were calculated.A total of 341 patients had VRE screening within 72 hours of SICU admission, with 32 VRE-positive (9%) and 309 VRE-negative (91%) patients. VRE-positive patients had a higher incidence of any HAI (78% vs. 35%, p < 0.001). Eight VRE-positive patients (25%) developed VRE HAI compared with only 3 VRE-negative patients (1%) (p < 0.001). VRE screening had a 73% sensitivity, 93% specificity, 25% PPV, and 99% NPV for determining subsequent VRE HAI.VRE colonization was present in 9% of SICU patients at admission. Negative VRE screen result had a high specificity and NPV for the development of subsequent VRE HAI. Empiric treatment of VRE infection may be unnecessary in VRE-negative patients.Prognostic/epidemiologic study, level III. Therapeutic study, level IV.

  View details for DOI 10.1097/TA.0000000000000203

  View details for PubMedID 24747448

• Breast-conserving therapy for triple-negative breast cancer. JAMA surgery Gangi, A., Chung, A., Mirocha, J., Liou, D. Z., Leong, T., Giuliano, A. E. 2014; 149 (3): 252-8

  Abstract

  The aggressive triple-negative phenotype of breast cancer (negative for estrogen and progesterone receptors and v-erb-b2 avian erythroblastic leukemia viral oncogene homolog 2 [ERBB2] [formerly human epidermal growth factor receptor 2 (HER2)]) is considered by some investigators to be a relative contraindication to breast-conserving therapy.To compare outcomes of breast-conserving therapy for patients with triple-negative breast cancer (TNBC) with those of patients with the luminal A, luminal B, and ERBB2 subtypes.Prospective database review at an academic tertiary medical center with a designated breast cancer center. We included 1851 consecutive patients ages 29 to 85 years with stages I to III invasive breast cancer who underwent breast-conserving therapy at a single institution from January 1, 2000, through May 30, 2012. Of these patients, 234 (12.6%) had TNBC; 1341 (72.4%), luminal A subtype; 212 (11.5%), luminal B subtype; and 64 (3.5%), ERBB2-enriched subtype.Breast-conserving therapy.The primary outcome measure was local recurrence (LR). Secondary outcome measures included regional recurrence, distant recurrence, and overall survival. RESULTS Triple-negative breast cancer was associated with younger age at diagnosis (56 vs 60 years; P = .001), larger tumors (2.1 vs 1.8 cm; P < .001), more stage II vs I cancer (42.1% vs 33.6%; P = .005), and more G3 tumors (86.4% vs 28.4%; P < .001) compared with the non-TNBC subtypes. Multivariable analysis showed that TNBC did not have a significantly increased risk of LR compared with the luminal A (hazard ratio, 1.4 [95% CI, 0.6-3.3]; P = .43), luminal B (1.6 [0.5-5.2]; P = .43), and ERBB2 (1.1 [0.2-5.2]; P = .87) subtypes. Only tumor size was a significant predictor of LR (hazard ratio, 4.7 [95% CI, 1.6-14.3]; P = .006). Predictors of worse overall survival included tumor size, grade, and stage and TNBC subtype.Breast-conserving therapy for TNBC is not associated with increased LR compared with non-TNBC subtypes. However, the TNBC phenotype correlates with worse overall survival. Breast-conserving therapy is appropriate for patients with TNBC.

  View details for DOI 10.1001/jamasurg.2013.3037

  View details for PubMedID 24382582

• Gastric Adjustable Band as a Retained Foreign Object: A Case Report BARIATRIC SURGICAL PRACTICE AND PATIENT CARE Felder, S. I., Liou, D. Z., Gangi, A. 2013; 8 (4): 166–68

  View details for DOI 10.1089/bari.2013.0004

  View details for Web of Science ID 000328567800010

• Surgical management of advanced adrenocortical carcinoma: a 21-year population-based analysis. The American surgeon Tran, T. B., Liou, D., Menon, V. G., Nissen, N. N. 2013; 79 (10): 1115-8

  Abstract

  Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with a dismal prognosis. When diagnosed in advanced stages of the disease, the outcomes of surgical resection are not well understood. The objective of this study is to determine the impact of surgery in patients with advanced ACC. Using the Surveillance, Epidemiology and End Results database, we identified patients diagnosed with Stage III and IV ACC between 1988 and 2009. A total of 320 patients with Stage III and IV disease were included in our analysis. In patients treated with surgical resection, the Stage III 1- and 5-year survival rates were 77 and 40 per cent, respectively, whereas the Stage IV 1- and 5-year survival rates were 54 and 27.6 per cent, respectively. Patients treated without surgery had poor survival at 1 year for both Stage III (13%) and Stage IV (16%) (P < 0.01 compared with the surgical groups). Lymph node dissection was performed in 26 per cent of the patients with advanced ACC and was associated with improved survival in univariate analysis of Stage IV patients. Overall, our results indicate that favorable survival outcomes can be achieved even in patients with Stage III and IV disease and surgery should be considered in patients with advanced ACC.

  View details for PubMedID 24160811

• Gender impacts mortality after traumatic brain injury in teenagers JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Ley, E. J., Short, S. S., Liou, D. Z., Singer, M. B., Mirocha, J., Melo, N., Bukur, M., Salim, A. 2013; 75 (4): 682–86

  Abstract

  Gender may influence outcomes following traumatic brain injury (TBI) although the mechanism is unknown. Animal TBI studies suggest that gender differences in endogenous hormone production may be the source. Limited retrospective clinical studies on gender present varied conclusions. Pediatric patients represent a unique population as pubescent children experience up-regulation of endogenous hormones that varies dramatically by gender. Younger children do not have these hormonal differences. The aim of this study was to compare pubescent and prepubescent females with males after isolated TBI to identify independent predictors of mortality.We performed a retrospective review of the National Trauma Data Bank Research Data Sets from 2007 and 2008 looking at all blunt trauma patients 18 years or younger who required hospital admission after isolated, moderate-to-severe TBI, defined as head Abbreviated Injury Scale (AIS) score 3 or greater. We excluded all individuals with AIS score of 3 or greater for any other region to limit the confounding effect of comorbidities. Based on the median age of menarche, we defined two age groups as follows: prepubescent (0-12 years) and pubescent (>12 years). Analysis was performed to compare trauma profiles and outcomes between groups. Our primary outcome measure was in-hospital mortality.A total of 20,280 patients met inclusion criteria; 10,135 were prepubescent, and 10,145 were pubescent. Overall mortality was 6.9%, and lower mortality was noted among prepubescent patients compared with pubescent (5.2% vs. 8.6%, p < 0.0001). Although female gender did not predict reduced mortality in the prepubescent cohort (adjusted odds ratio, 1.05; 95% confidence interval, 0.85-1.30; p = 0.63), female gender was associated with reduced mortality in the pubescent (adjusted odds ratio, 0.78; 95% confidence interval, 0.65-0.93; p = 0.007).In contrast to prepubescent female gender, pubescent female gender predicts reduced mortality following isolated, moderate-to-severe TBI. Endogenous hormonal differences may be a contributing factor and require further investigation.Prognostic study, level III.

  View details for DOI 10.1097/TA.0b013e31829d024f

  View details for Web of Science ID 000330457400020

  View details for PubMedID 24064883

• Supratherapeutic vancomycin levels after trauma predict acute kidney injury and mortality. The Journal of surgical research Ley, E. J., Liou, D. Z., Singer, M. B., Mirocha, J., Srour, M., Bukur, M., Margulies, D. R., Salim, A. 2013; 184 (1): 501-6

  Abstract

  High-dose vancomycin is increasingly prescribed for critically ill trauma patients at risk for methicillin-resistant Staphylococcus aureus pneumonia. Although trauma patients have multiple known risk factors for acute kidney injury (AKI), a link between vancomycin and AKI or mortality has not been established. We hypothesize that high vancomycin trough concentration (VT) after trauma is associated with AKI and increased mortality.This was a retrospective analysis from a single institution Level I trauma center. Data were reviewed for all adult trauma patients who were admitted between 2006 and 2010. Patients were included if they received intravenous vancomycin, had serum creatinine levels before and after vancomycin administration, and had at least one recorded VT. Patients were stratified by VT into four groups: VT1 = 0-10 mg/L, VT2 = 10.1-15 mg/L, VT3 = 15.1-20 mg/L, VT4 >20 mg/L. Multivariable logistic regression was performed to determine the association between VT, AKI, and mortality.Of the 6781 trauma patients reviewed, 263 (3.9%) fit inclusion criteria. Ninety-seven (36.9%) patients developed AKI and 25 (9.5%) died. AKI and mortality increased progressively with VT. Ninety-one patients (34.6%) had troughs >20 mg/L and VT4 was independently associated with AKI (AOR 4.7, P < 0.01) and mortality (AOR 4.8, P = 0.05).AKI is common in trauma patients who receive intravenous vancomycin. A supratherapeutic trough level of >20 mg/L is an independent predictor of AKI and mortality in trauma patients.

  View details for DOI 10.1016/j.jss.2013.04.047

  View details for PubMedID 23731689

• Midodrine: a novel therapeutic for refractory chylothorax. Chest Liou, D. Z., Warren, H., Maher, D. P., Soukiasian, H. J., Melo, N., Salim, A., Ley, E. J. 2013; 144 (3): 1055-1057

  Abstract

  Thoracic duct injury is a rare but serious complication following surgery of the neck or chest that leads to uncontrolled chyle leak. Conventional management includes drainage, nutritional modification, or aggressive surgical interventions such as thoracic duct ligation, flap coverage, fibrin glue, or talc pleurodesis; few successful medical therapeutics are available. We report a case of a high-output chylothorax refractory to aggressive medical and surgical interventions. Chyle output decreased substantially after initiating midodrine, an α1-adrenergic agonist that causes vasoconstriction of the lymph system, reducing chyle flow. This case report suggests that midodrine may be a novel therapeutic for refractory chyle leaks.

  View details for DOI 10.1378/chest.12-3081

  View details for PubMedID 24008957

• Emergency department blood transfusion: the first two units are free JOURNAL OF SURGICAL RESEARCH Ley, E. J., Liou, D. Z., Singer, M. B., Mirocha, J., Melo, N., Chung, R., Bukur, M., Salim, A. 2013; 184 (1): 546–50

  Abstract

  Studies on blood product transfusions after trauma recommend targeting specific ratios to reduce mortality. Although crystalloid volumes as little as 1.5 L predict increased mortality after trauma, little data is available regarding the threshold of red blood cell (RBC) transfusion volume that predicts increased mortality.Data from a level I trauma center between January 2000 and December 2008 were reviewed. Trauma patients who received at least 100 mL RBC in the emergency department (ED) were included. Each unit of RBC was defined as 300 mL. Demographics, RBC transfusion volume, and mortality were analyzed in the nonelderly (<70 y) and elderly (≥70 y). Multivariate logistic regression was performed at various volume cutoffs to determine whether there was a threshold transfusion volume that independently predicted mortality.A total of 560 patients received ≥100 mL RBC in the ED. Overall mortality was 24.3%, with 22.5% (104 deaths) in the nonelderly and 32.7% (32 deaths) in the elderly. Multivariate logistic regression demonstrated that RBC transfusion of ≥900 mL was associated with increased mortality in both the nonelderly (adjusted odds ratio 2.06, P = 0.008) and elderly (adjusted odds ratio 5.08, P = 0.006).Although transfusion of greater than 2 units in the ED was an independent predictor of mortality, transfusion of 2 units or less was not. Interestingly, unlike crystalloid volume, stepwise increases in blood volume were not associated with stepwise increases in mortality. The underlying etiology for mortality discrepancies, such as transfusion ratios, hypothermia, or immunosuppression, needs to be better delineated.

  View details for DOI 10.1016/j.jss.2013.03.043

  View details for Web of Science ID 000323609400088

  View details for PubMedID 23578753

• Insurance type, not race, predicts mortality after pediatric trauma. The Journal of surgical research Short, S. S., Liou, D. Z., Singer, M. B., Bloom, M. B., Margulies, D. R., Bukur, M., Salim, A., Ley, E. J. 2013; 184 (1): 383-7

  Abstract

  In adult trauma, mortality varies with race and insurance status. In the elderly, insurance type has little impact on mortality after trauma and the influence of race is reduced. How race and insurance affect pediatric trauma requires further attention. We hypothesized that mortality after pediatric trauma is influenced by insurance type and not race.We reviewed all cases of blunt trauma in children ≤13 y requiring admission, using the National Trauma Data Bank Research Data Sets for 2007 and 2008. Exclusions included an Abbreviated Injury Score of 6 for any body region, dead on arrival, and missing data. Our primary outcome measure was in-hospital mortality.We identified 831 Asian (1.2%), 10,592 black (15.5%), 45,173 white (66.2%), and 8498 Hispanic (12.5%) children, and 3161 children (4.6%) classified as other race. Mean age was 7.4 ± 4.5 y, 11.9% were uninsured, and overall in-hospital mortality was 1.4%. Multivariable modeling indicated that race was not associated with increased mortality (Asian versus white, adjusted odds ratio [AOR] 1.05, P = 0.88; black versus white, AOR 0.92, P = 0.42; Hispanic versus white, AOR 0.87, P = 0.26; and other race versus white, AOR 1.01, P = 0.96). In contrast, insurance status (any insurance versus no insurance, AOR 0.6, P < 0.01) and insurance type (private insurance versus no insurance, AOR 0.47, P < 0.01; Medicaid versus no insurance, 0.67, P < 0.01) predicted reduced mortality.Insurance status and insurance type are important predictors of mortality after pediatric trauma while, in contrast, race is not.

  View details for DOI 10.1016/j.jss.2013.03.042

  View details for PubMedID 23582228

• Does a history of postoperative ileus predispose to recurrent ileus after multistage ileal pouch-anal anastomosis? Techniques in coloproctology Le, Q., Liou, D. Z., Murrell, Z., Fleshner, P. 2013; 17 (4): 383-8

  Abstract

  Although postoperative ileus (POI) is a common complication after major abdominal colorectal surgery, it is unknown whether a history of POI predisposes to recurrent POI in subsequent surgeries. In the present retrospective case-control study, conducted at the colorectal surgery division of a tertiary care center, we attempted to identify factors that may predict recurrent POI in ulcerative colitis (UC) patients undergoing three-stage ileal pouch-anal anastomosis (IPAA).Charts of UC patients undergoing three-stage IPAA were reviewed. All patients received a standardized accelerated postoperative care pathway. Patients were assigned to one of 3 categories: Group A patients did not have POI after either initial subtotal colectomy (STC) or subsequent IPAA, Group B patients developed POI only after initial STC, and Group C patients developed POI after both STC and IPAA.The study group consisted of 91 patients. There were 71 (78 %) patients in Group A, 14 (15 %) patients in Group B, and 6 (7 %) patients in group C. There was no significant difference in any demographic or clinical features among patients that developed no POI, those that developed POI only after STC, and those that developed POI after both STC and IPAA.POI is difficult to predict after first- and second-stage IPAA. Clinical factors and a history of POI from first-stage IPAA do not predict POI after second-stage IPAA. Patients with a history of POI after STC do not have an increased risk of developing recurrent POI.

  View details for DOI 10.1007/s10151-012-0942-2

  View details for PubMedID 23183687

• Insurance-and race-related disparities decrease in elderly trauma patients. The journal of trauma and acute care surgery Singer, M. B., Liou, D. Z., Clond, M. A., Bukur, M., Mirocha, J., Margulies, D. R., Salim, A., Ley, E. J. 2013; 74 (1): 312-6

  Abstract

  Little focus is on health care disparities in the elderly, a population largely covered by public insurance. We characterized insurance type and race in elderly trauma patients to determine if lack of insurance or minority status predict increased mortality.The National Trauma Data Bank (version 7.0) was queried for all adult blunt trauma patients. We divided patients into two cohorts (15-64 or ≥ 65 years) based on age for universal Medicare eligibility. Our primary outcome measure was in-hospital mortality. Multiple logistic regression was used to control for confounding variables.A total of 541,471 patients met inclusion criteria. Among younger patients, the most common insurance type was private (41.0%), with 26.9% uninsured. In contrast, the most common insurance type among older patients was Medicare (64.6%), with 6.0% uninsured. Within the younger cohort, private insurance (adjusted odds ratio [AOR], 0.6; p < 0.01) and other insurance (AOR, 0.8; p < 0.01) predicted reduced mortality, while Medicare predicted similar mortality (AOR, 1.1; p = 0.18) compared with no insurance. Black race (AOR, 1.4; p < 0.01) and Hispanic ethnicity (AOR, 1.4; p < 0.01) predicted higher mortality compared with white race. Within the older cohort, no insurance predicted similar mortality as Medicare (AOR, 1.0; p = 0.43), private insurance (AOR, 1.0; p = 0.51), and other insurance (AOR, 1.0; p = 0.71). Hispanic ethnicity predicted increased mortality (AOR, 1.4; p < 0.01), while Asian race was protective (AOR, 0.7; p = 0.01) compared with white race.Elderly trauma patients present primarily with Medicare, while younger trauma patients are mostly privately insured; elderly patients are four times more likely to be insured. Disparities caused by lack of insurance and minority race are reduced in elderly trauma patients.Epidemiologic/prognostic study, level III.

  View details for DOI 10.1097/TA.0b013e31826fc899

  View details for PubMedID 23147178

• Acute kidney injury in elderly trauma: not associated with admission IV contrast. J Trauma Treat Liou, D. Z., Berry, C., Singer, M. B., Rudd, S., Torbati, S. S., Silka, P. A., Bukur, M., Salim, A., Ley, E. J. 2013; 2 (172)

  View details for DOI 10.4172/2167-122.1000172.

• Support for blood alcohol screening in pediatric trauma. American journal of surgery Ley, E. J., Singer, M. B., Short, S. S., Liou, D., Bukur, M., Malinoski, D. J., Margulies, D. R., Salim, A. 2012; 204 (6): 939-43; discussion 943

  Abstract

  Alcohol intoxication in pediatric trauma is underappreciated. The aim of this study was to characterize alcohol screening rates in pediatric trauma.The Los Angeles County Trauma System Database was queried for all patients aged ≤ 18 years who required admission between 2003 and 2008. Patients were compared by age and gender.A total of 18,598 patients met the inclusion criteria; 4,899 (26.3%) underwent blood alcohol screening, and 2,797 (57.1%) of those screened positive. Screening increased with age (3.3% for 0-9 years, 15.1% for 10-14 years, and 45.4% for 15-18 years; P < .01), as did alcohol intoxication (1.9% for 0-9 years, 5.8% 10-14 years, and 27.3% for 15-18 years; P < .01). Male gender predicted higher mortality in those aged 15 to 18 years (adjusted odds ratio, 1.7; P < .01), while alcohol intoxication did not (adjusted odds ratio, .97; P = .84).Alcohol intoxication is common in adolescent trauma patients. Screening is encouraged for pediatric trauma patients aged ≥10 years who require admission.

  View details for DOI 10.1016/j.amjsurg.2012.05.018

  View details for PubMedID 23026384

• Increasing intent to donate in Hispanic American high school students: results of a prospective observational study. Transplantation proceedings Salim, A., Berry, C., Ley, E. J., Liou, D. Z., Schulman, D., Navarro, S., Zheng, L., Chan, L. S. 2012; 45 (1): 13-9

  Abstract

  High school students are an important target audience for organ donation education. A novel educational intervention focused on Hispanic American (HA) high school students might improve organ donation rates.A prospective observational study was conducted in five Los Angeles High Schools with a high percentage of HA students. A "culturally sensitive" educational program was administered to students in grades 9 to 12. Preintervention surveys that assessed awareness, knowledge, perception, and beliefs regarding donation as well as the intent to become an organ donor were compared to postintervention surveys.A total of 10,146 high school students participated in the study. After exclusions, 4876 preintervention and 3182 postintervention surveys were analyzed. A significant increase in the overall knowledge, awareness, and beliefs regarding donation was observed after the intervention, as evidenced by a significant increase in the percentage of correct answers on the survey (41% pre- versus 44% postintervention, P < .0001). When specifically examining HA students, there was a significant increase in the intent to donate organs (adjusted odds ratio 1.21, 95% confidence interval: 1.09, 1.34, P = .0003).This is the first study to demonstrate a significant increase in the intent to donate among HA high school students following an educational intervention.

  View details for DOI 10.1016/j.transproceed.2012.08.009

  View details for PubMedID 23375270

  View details for PubMedCentralID PMC3564055

• Preoperative FDG-PET for axillary metastases in patients with breast cancer. Archives of surgery (Chicago, Ill. : 1960) Chung, A., Liou, D., Karlan, S., Waxman, A., Fujimoto, K., Hagiike, M., Phillips, E. H. 2006; 141 (8): 783-8; discussion 788-9

  Abstract

  Fludeoxyglucose F 18 (FDG) positron emission tomography (PET) can be used to predict axillary node metastases.Case series.Comprehensive breast care center.Fifty-one women with 54 biopsy-proven invasive breast cancers.Whole-body FDG-PET performed before axillary surgery and interpreted blindly.Axillary FDG activity, quantified by standardized uptake value (SUV); axillary metastases, quantified histologically; and tumor characteristics.There was PET activity in 32 axillae (59%). The SUVs ranged from 0.7 to 11.0. Twenty tumors had an SUV of 2.3 or greater, and 34 had an SUV of less than 2.3. There were no significant differences between these 2 groups except in axillary metastasis size (SUV /=2.3): mean age, 53 vs 58 years (P = .90); mean modified Bloom-Richardson score, 7.7 vs 7.6 (P = .20); lymphovascular invasion present, 25% vs 36% (P = .40); mean Ki-67 level, 25% vs 32% (P = .20); mean tumor size, 2.9 vs 3.2 cm (P = .05); and axillary metastasis size, 0.9 vs 1.7 (P = .001). By adopting an SUV threshold of 2.3, FDG-PET had a sensitivity of 60%, a specificity of 100%, and a positive predictive value of 100%.Patients with an SUV greater than 2.3 had axillary metastases. This finding obviates the need for sentinel lymph node biopsy or needle biopsy to diagnose axillary involvement. Surgeons can proceed to axillary node dissection to assess the number of nodes involved, eliminate axillary disease, or perhaps provide a survival benefit if preoperative FDG-PET has an SUV greater than 2.3.

  View details for DOI 10.1001/archsurg.141.8.783

  View details for PubMedID 16924086

• Selective nonoperative management of abdominal stab wounds: prospective, randomized study. World journal of surgery Leppäniemi, A. K., Haapiainen, R. K. 1996; 20 (8): 1101-5; discussion 1105-6

  Abstract

  In a prospective, randomized trial the safety and cost-effectiveness of selective nonoperative management was compared to mandatory laparotomy in patients with abdominal stab wounds not requiring immediate laparotomy for hemodynamic instability, generalized peritonitis, or evisceration of abdominal contents. Fifty-one patients were randomly assigned to mandatory laparotomy or expectant nonoperative management and compared for early (<90 days) mortality and morbidity, length of hospital stay, and hospital costs. There was no early mortality. The morbidity rate was 19% following mandatory laparotomy and 8% after observation (p = 0.26). Four patients (17%) managed nonoperatively required delayed laparotomy. The hospital stay was shorter in the observation group (median 2 days versus 5 days;p = 0.002). About $2800 (US) was saved for every patient who underwent successful nonoperative management. It is concluded that selective nonoperative management of abdominal stab wounds, although resulting in delayed laparotomy in some patients, is safe and the preferred strategy for minimizing the days in hospital with concomitant savings in hospital costs. Mandatory laparotomy detects some unexpected organ injuries earlier and more accurately but results in a high nontherapeutic laparotomy rate and surgical management of minor injuries that in many cases could be managed nonoperatively.

  View details for PubMedID 8798372