- To Wait or Not to Wait? Covid-19 Vaccination Mitigates Adverse Surgical Outcomes. Annals of surgery 2022
Partial Tendon Injury at the Tendon-to-Bone Enthesis Activates Skeletal Stem Cells.
Stem cells translational medicine
The tendon enthesis plays a critical role in facilitating movement and reducing stress within joints. Partial enthesis injuries heal in a mechanically inferior manner and never achieve healthy tissue function. The cells responsible for tendon-to-bone healing remain incompletely characterized and their origin is unknown. Here, we evaluated the putative role of mouse skeletal stem cells (mSSCs) in the enthesis after partial-injury. We found that mSSCs were present at elevated levels within the enthesis following injury and that these cells downregulated TGFβ signaling pathway elements at both the RNA and protein levels. Exogenous application of TGFβ post-injury led to a reduced mSSC response and impaired healing, whereas treatment with a TGFβ inhibitor (SB43154) resulted in a more robust mSSC response. Collectively, these data suggest that mSSCs may augment tendon-to-bone healing by dampening the effects of TGFβ signaling within the mSSC niche.
View details for DOI 10.1093/stcltm/szac027
View details for PubMedID 35640155
- Freezing the Future. Annals of surgery 1800
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
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
- Commentary: Inspiring a New Generation of Healthcare Workers. Seminars in thoracic and cardiovascular surgery 2021
- The role of gender in non-small cell lung cancer: a narrative review JOURNAL OF THORACIC DISEASE 2021; 13 (6): 3816-3826
The role of gender in non-small cell lung cancer: a narrative review.
Journal of thoracic disease
2021; 13 (6): 3816-3826
The role of gender in the development, treatment and prognosis of thoracic malignancies has been underappreciated and understudied. While most research has been grounded in tobacco-related malignancies, the incidence of non-smoking related lung cancer is on the rise and disproportionately affecting women. Recent research studies have unveiled critical differences between men and women with regard to risk factors, timeliness of diagnosis, incongruent screening practices, molecular and genetic mechanisms, as well as response to treatment and survival. These studies also highlight the increasingly recognized need for targeted therapies that account for variations in the response and complications as a function of gender. Similarly, screening recommendations continue to evolve as the role of gender is starting to be ellucidated. As women have been underrepresented in clinical trials until recently, the data regarding optimal care and outcomes is still lagging behind. Understanding the underlying similarities and differences between men and women is paramount to providing adequate care and prognostication to patients of either gender. This review provides an overview of the critical role that gender plays in the care of patients with non-small cell lung cancer and other thoracic malignancies, with an emphasis on the need for increased awareness and further research to continue elucidating these disparities.
View details for DOI 10.21037/jtd-20-3128
View details for PubMedID 34277072
View details for PubMedCentralID PMC8264700
Impact of the Surgical Approach to Thymectomy Upon Complete Stable Remission Rates in Myasthenia Gravis: A Meta-analysis.
OBJECTIVES: To determine whether the available operative techniques for thymectomy in myasthenia gravis (MG) confer variable chances for achieving complete stable remission (CSR), we performed a meta-analysis of comparative studies of surgical approaches to thymectomy.METHODS: Meta-analysis of all studies providing comparative data on thymectomy approaches, with CSR reported and minimum 3 years mean follow-up.RESULTS: 12 cohort studies and one randomized clinical trial, containing 1598 patients, met entry criteria. At 3 years, CSR from MG was similar following VATS extended vs. both basic (RR 1.00, p=1.00, 95% CI 0.39-2.58) and extended (RR 0.96, p=0.74, CI: 0.72-1.27) transsternal approaches. CSR at 3 years was also similar following extended transsternal vs. combined transcervical-subxiphoid (RR 1.08, p=0.62, CI: 0.8-1.44) approaches. VATS extended approaches remained statistically equivalent to extended transsternal approaches through 9 years of follow-up (RR 1.51, p=0.05, CI: 0.99-2.30). The only significant difference in CSR rate between a traditional open and a minimally invasive approach was seen at 10 years when comparing the now-abandoned basic (non-sternum-lifting) transcervical approach and the extended transsternal approach (RR 0.4, p=0.01, CI: 0.2-0.8).CONCLUSIONS: A significant difference in the rate of CSR among various surgical approaches for thymectomy in MG was identified only at long-term follow-up, and only between what might be considered the most aggressive approach (extended transsternal thymectomy) and the least aggressive approach (basic transcervical thymectomy). Extended minimally invasive approaches appear to have equivalent CSR rates to extended transsternal approaches and are therefore appropriate in the hands of experienced surgeons.
View details for DOI 10.1212/WNL.0000000000012153
View details for PubMedID 33947783
Impact of policy-based and institutional interventions on postoperative opioid prescribing practices.
American journal of surgery
BACKGROUND: We assessed the impact of policy-based and institutional interventions to limit postoperative opioid prescribing.METHODS: Retrospective cohort study of patients who underwent laparoscopic/open appendectomies, laparoscopic/open cholecystectomies, and laparoscopic/open inguinal hernia repair during a 6-month interval in 2018 (control), 2019 (post-policy intervention), and 2020 (post-institutional intervention) to assess changes in postoperative opioid prescribing patterns. A survey was collected for the 2020 cohort.RESULTS: Comparing the 762 patients identified in 2018, 2019, and 2020 cohorts there was a significant decrease in mean opioid tabs prescribed (23.5±8.9 vs. 16.2±7.0 vs. 12.8±4.9, p<0.01) and mean OME dosage (148.0±68.0 vs. 108.6±51.8 vs. 95.4±38.0, p<0.01), without a difference in refill requests. Patient survey (response rate 63%) indicated 91.4% of patients reported sufficient pain control.CONCLUSION: Formalized opioid-prescribing guidelines and statewide regulations can significantly decrease postoperative opioid prescribing with good patient satisfaction. Surgeon education may facilitate efforts to minimize narcotic over-prescription without compromising pain management.
View details for DOI 10.1016/j.amjsurg.2021.02.004
View details for PubMedID 33593614
Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries
2021; 397 (10272): 387–97
80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.National Institute for Health Research Global Health Research Unit.
View details for DOI 10.1016/S0140-6736(21)00001-5
View details for Web of Science ID 000614227700026
View details for PubMedID 33485461
View details for PubMedCentralID PMC7846817
- Author Spotlight: Ioana Baiu. Digestive diseases and sciences 2021
- Cec and You Shall Find: Cecal Perforation in a Patient with COVID-19. Digestive diseases and sciences 2021
- Carotid Artery Stenting. JAMA 2020; 324 (16): 1690
- Esophageal Cancer Surgery. JAMA 2020; 324 (15): 1580
- Carotid Artery Endarterectomy. JAMA 2020; 324 (1): 110
- Periorbital and Orbital Cellulitis. JAMA 2020; 323 (2): 196
Understanding Health Care Utilization and Mortality After Emergency General Surgery in Patients With Underlying Liver Disease.
The American surgeon
2020; 86 (6): 665–74
Mortality and complications are not well defined nationally for emergency general surgery (EGS) patients presenting with underlying all-cause liver disease (LD).We analyzed the 2012-2014 National Inpatient Sample for adults (aged ≥ 18 years) with a primary EGS diagnosis. Underlying LD included International Classification of Diseases, Ninth Revision, Clinical Modification codes for alcoholic and viral hepatitis, malignancy, congenital etiologies, and cirrhosis. The primary outcome was mortality; secondary outcomes included complications, operative intervention, and costs.Of the 6.8 million EGS patients, 358 766 (5.3%) had underlying LD. 59.1% had cirrhosis, 6.7% had portal hypertension, and 13.7% had ascites. Compared with other EGS patients, EGS-LD patients had higher mean costs ($12 847 vs $10 234, P < .001). EGS-LD patients were less likely to have surgery (26.1% vs 37.0%, P < .001) but for those who did, mortality was higher (4.8% vs 1.8%, P < .001). Risk factors for mortality included ascites (adjusted odds ratio [aOR] = 2.68, P < .001), dialysis (aOR = 3.44, P < .001), sepsis (aOR = 8.97, P < .001), and respiratory failure requiring intubation (aOR = 10.40, P < .001). Odds of death increased in both surgical (aOR = 4.93, P < .001) and non-surgical EGS-LD patients (aOR = 2.56, P < .001).Underlying all-cause LD among EGS patients is associated with increased in-hospital mortality, even in the absence of surgical intervention.
View details for DOI 10.1177/0003134820923304
View details for PubMedID 32683972
- The Cava. Trauma surgery & acute care open 2020; 5 (1): e000480
A National Analysis of Minimally Invasive vs Open Segmentectomy for Stage IA Non-small-cell Lung Cancer.
Seminars in thoracic and cardiovascular surgery
The objective of this study was to compare long-term outcomes of open versus minimally invasive (MIS) segmentectomy for early stage non-small-cell lung cancer (NSCLC), which has not been evaluated using national studies. Outcomes of open versus MIS segmentectomy for clinical T1, N0, M0 NSCLC in the National Cancer Data Base (2010-2015) were evaluated using propensity score matching. Of the 39,351 patients who underwent surgery for stage IA NSCLC from 2010-2015, 770 underwent segmentectomy by thoracotomy and 1,056 by MIS approach (876 thoracoscopic [VATS], 180 robotic). The MIS to open conversion rate was 6.7% (n=71). After propensity-score matching, all baseline characteristics were well-balanced between the open (n=683) and MIS (n=683) groups. When compared to the open group, the MIS group had shorter median length of stay (LOS) (4 vs 5 days, p<0.001) and lower 30-day mortality (0.6% vs 1.9%, p=0.037). There were no significant differences between MIS and open groups with regard to 30-day readmission (5.0% vs 3.7%, p=0.43), or upstaging from cN0 to pN1/N2/N3 (3.1% vs 3.6%, p=0.89). The MIS approach was associated with similar long-term overall survival as the open approach (5-year survival: 62.3% vs 63.5%, p=0.89; multivariable-adjusted HR: 0.99, 95% CI: 0.82-1.21, p=0.96). In this national analysis of open versus MIS segmentectomy for clinical stage IA NSCLC, MIS was associated with shorter LOS and lower perioperative mortality, and similar nodal upstaging and 5-year survival when compared to segmentectomy via thoracotomy. MIS segmentectomy does not appear to compromise oncologic outcomes for clinical stage IA NSCLC.
View details for DOI 10.1053/j.semtcvs.2020.09.009
View details for PubMedID 32977013
- The Trauma Scene. JAMA 2020; 324 (4): 406
- Paraesophageal Hernia Repair and Fundoplication. JAMA 2019; 322 (24): 2450
- What Is a Paraesophageal Hernia? JAMA 2019; 322 (21): 2146
- What Is a Tracheostomy? JAMA 2019; 322 (19): 1932
- Enteral Nutrition. JAMA 2019; 321 (20): 2040
2019; 321 (18): 1836
View details for PubMedID 31087024
- Croup. JAMA 2019; 321 (16): 1642
Minimally Invasive Small Bowel Cancer Surgery.
Surgical oncology clinics of North America
2019; 28 (2): 273–83
Small bowel malignancies are extremely rare. Surgical resection is often the mainstay of treatment with the extent of the operation depending on the type of tumor. Whereas neuroendocrine tumors and adenocarcinoma require lymph node resection, gastrointestinal stromal tumors do not typically metastasize to regional nodes and therefore need resection only. Minimally invasive approaches are applicable to small tumors that require a limited resection and reconstruction and have been shown to have equal survival benefits with decreased risk of postoperative complications.
View details for PubMedID 30851828
- Minimally Invasive Small Bowel Cancer Surgery SURGICAL ONCOLOGY CLINICS OF NORTH AMERICA 2019; 28 (2): 273-+
- Parenteral Nutrition. JAMA 2019; 321 (21): 2142
- Epiglottitis. JAMA 2019; 321 (19): 1946
- Sigmoid Volvulus. JAMA 2019; 321 (24): 2478
- Mucormycosis emboli: a rare cause of segmental bowel ischemia. Trauma surgery & acute care open 2019; 4 (1): e000305
- Acute severe iatrogenic hyponatremia. Trauma surgery & acute care open 2019; 4 (1): e000388
Necrotizing Soft Tissue Infections.
2019; 321 (17): 1738
View details for PubMedID 31063576
- Rhinovirus-associated severe acute respiratory distress syndrome (ARDS) managed with airway pressure release ventilation (APRV). Trauma surgery & acute care open 2019; 4 (1): e000322
Talc Pleurodesis: a Medical, Medicolegal, and Socioeconomic Review.
The Annals of thoracic surgery
Talcum has been used in pleurodesis for over eight decades. Despite a wealth of research, controversy remains over the optimal sclerosant for pneumothorax and pleural effusions. Talc's historical primacy has been challenged due to its potential for pulmonary toxicity, possible carcinogenicity, and recent concerns surrounding availability and legal liability, making an ideal time for a review.This is a systematic review of the talc literature, focused on publications after the year 2000 evaluating mechanism of action, efficacy, side-effect profile, and alternative sclerosants; included is an overview of current socioeconomic and legal controversies.The data support talc as the most effective agent for pleurodesis. There is evidence to suggest that mean particle size has a direct relationship to the side-effect profile and that significant hypoxemic events following talc administration are exceedingly rare using available graded talc preparations. Concerns regarding the development of malignancies following topical talc application remain incompletely resolved but appear related to cosmetic powder preparations that were contaminated with asbestos. Purified talc in the pleural space has not been implicated. Recent difficulties accessing commercial talc preparations have been solved. Although safe and effective talc alternatives do exist, these agents are not as well studied.Talc pleurodesis with modern, purified, graded talc preparations is safe and highly effective. Talc is an inexpensive and accessible option that remains appropriate for pleurodesis despite existing controversies.
View details for DOI 10.1016/j.athoracsur.2019.08.104
View details for PubMedID 31593652
Caring for Caregivers - Resident Physician Health and Wellbeing.
Journal of surgical education
There is a national epidemic of physician burnout and serious concerns exist regarding the well-being of future physicians. This project seeks to address resident physician health, by creating a sense of support and community during training, as a method to target one of the many facets of burnout.We created a program that allows residents who fall ill to receive a health package, delivered to work or home, consisting of essential medications, vitamins, nutrition, and hydration. The recipients were asked to answer a short survey regarding their experience.Stanford Health Care, Department of Surgery, Division of General Surgery, Palo Alto California.Eighteen packages have been delivered since the start of the project. One hundred percent of residents agree that this program fulfills an otherwise unmet need in residency. Similarly, all felt that the supplies they received helped them recover faster. The majority (83%) of the packages were requested by colleagues of the ill residents.We present an innovative project aimed at improving resident physician health, fostering a feeling of support, and helping to reduce resident burnout. This is the first report of a program of this kind and we hope that it incentivizes a broader discussion and implementation of similar initiatives in other residency programs across the country.
View details for DOI 10.1016/j.jsurg.2019.08.007
View details for PubMedID 31494061
- When Lightning Strikes Twice DIGESTIVE DISEASES AND SCIENCES 2018; 63 (10): 2536–40
- Small Bowel Obstruction. JAMA 2018; 319 (20): 2146
- Skin Abscess. JAMA 2018; 319 (13): 1405
- Anaphylaxis in Children. JAMA 2018; 319 (9): 943
- Nursemaid's Elbow (Elbow Subluxation). JAMA 2018; 319 (5): 515
When Lightning Strikes Twice.
Digestive diseases and sciences
View details for PubMedID 29302877