Lillian L. Tsai, MD

All Publications

• Accuracy of DOTATATE-positron emission tomography for preoperative nodal staging of carcinoid tumors of the lung. JTCVS open Tsai, L. L., Bommakanti, S., Sridharan, S., Myall, N. J., Guenthart, B. A., Liou, D. Z., Lui, N. S., Backhus, L. M., Berry, M. F., Shrager, J. B., Elliott, I. A. 2025; 27: 157-163

  Abstract

  DOTATATE-positron emission tomography (PET) scans use a radiotracer that binds somatostatin receptor 2 on neuroendocrine cells to identify carcinoid tumors. Use of DOTATATE-PET during preoperative evaluation of lung carcinoids is increasing, but the accuracy of DOTATATE-PET in nodal staging of pulmonary carcinoids is unknown.We reviewed patients with lung carcinoids undergoing DOTATATE-PET before surgical resection between November 2013 and 2023. Exclusions included non-avid primary tumors on DOTATATE-PET or absent pathologic lymph node assessment. Using surgical pathology as the gold standard, we assessed concordance between DOTATATE-PET-based clinical stage and postoperative pathologic stage. Sensitivity, specificity, negative predictive value, and positive predictive value were calculated, with χ2 and Mann-Whitney U test used for comparisons.Among 58 patients undergoing resection of lung carcinoid tumors (48 typical, 10 atypical carcinoids), 15 (25.8%) had pathologic nodal involvement, but DOTATATE-PET detected only 3. For the 43 patients who were pathologic node-negative, DOTATATE-PET was negative in 42. This yielded 42 true negatives, 3 true positives, 12 false negatives, and 1 false positive, with sensitivity of 20%, specificity 97.7%, negative predictive value 77.8%, positive predictive value 75%, and overall accuracy of 77.6%. Larger tumor size was significantly associated with inaccurate DOTATATE-PET (P = .03). No other clinical characteristics significantly correlated with DOTATATE-PET accuracy.DOTATATE-PET has poor sensitivity for nodal disease in patients with pulmonary carcinoid tumors. Thorough pathologic lymph node evaluation is necessary regardless of DOTATATE-PET results when resecting carcinoid tumors. Given that primary surgery is indicated even if it were known there were positive lymph nodes, the utility of a DOTATATE-PET is likely limited.

  View details for DOI 10.1016/j.xjon.2025.07.018

  View details for PubMedID 41169312

  View details for PubMedCentralID PMC12570576

• Modern Preoperative Evaluation for Lung Cancer Treatment. Surgical oncology clinics of North America Tsai, L. L., Elliott, I. A. 2025; 34 (4): 501-512

  Abstract

  Preoperative evaluation is crucial for ensuring optimal patient selection and minimizing surgical risk. Advances in surgical techniques, including minimally invasive procedures and sublobar resection, have broadened the pool of patients eligible for resection. Incorporating modern technologies and thorough risk assessment is essential for enhancing preoperative optimization and improving patient outcomes. Staying current with these evolving approaches allows for better management of comorbidities, physical status, and surgical readiness, ultimately contributing to more successful surgery and recovery. By integrating the latest tools and strategies, health care providers can improve both short-term and long-term outcomes for patients with lung cancer.

  View details for DOI 10.1016/j.soc.2025.03.007

  View details for PubMedID 41110869

• Metastasectomy in Thymic and Germ Cell Tumors. Thoracic surgery clinics Tsai, L. L., Lui, N. S. 2025; 35 (2): 267-271

  Abstract

  Pulmonary metastasectomy is a scarcely studied topic for germ cell and thymic tumors. There is evidence showing that pulmonary metastasectomy provides a long-term survival benefit in germ cell tumors. Surgical management of thymic tumor recurrence in the thoracic cavity is generally recommended. Chemoradiation therapies and a multidisciplinary assessment are critical in these cases. The surgical approach should be tailored to the specific patient and location of metastases.

  View details for DOI 10.1016/j.thorsurg.2024.11.008

  View details for PubMedID 40246416

• The impact of extent of nodal involvement on stage IIIA (N2) non-small cell lung cancer outcomes. JTCVS open Wong, L. Y., Tsai, L. L., He, H., Elliott, I. A., Berry, M. F. 2025; 23: 256-265

  Abstract

  Stage IIIA (N2) non-small cell lung cancer (NSCLC) treatment can depend on the extent of nodal involvement, with surgery considered for limited disease and definitive chemoradiation preferred for bulky or multi-station disease. Evidence to support management is limited. This study evaluated the impact of the extent of stage IIIA (N2) nodal involvement on outcomes after surgery.Patients who underwent surgical resection of T1-2N2M0 NSCLC in the Surveillance, Epidemiology, and End Results database from 2004 to 2019 were stratified as having limited (1 positive node) versus more extensive (>1 positive node) nodal disease, and survival was evaluated with Kaplan-Meier and Cox analyses.Of the 6933 patients identified surgical patients, 2129 (30.7%) had limited nodal disease whereas 4804 (69.3%) had more extensive nodal involvement. The limited nodal group had greater 5-year overall survival than the more extensive node group (39.3% vs 30.3%, P < .001), and more extensive nodal involvement (hazard ratio, 1.26; P < .001) was independently associated with worse survival in Cox analysis. Surgical patients had a greater 5-year overall survival than 1644 comparable N2 patients with extensive nodal involvement who received definitive chemoradiation (30.9% vs 18.9%, P < .001).Increasing nodal involvement is associated with worse survival for patients with stage IIIA (N2) NSCLC but select patients with more extensive nodal disease may still benefit from surgery compared to chemoradiation.

  View details for DOI 10.1016/j.xjon.2024.11.018

  View details for PubMedID 40061550

  View details for PubMedCentralID PMC11883707

• Endoscopic Findings Predictive of Pathologic Upstaging in T2N0 Esophageal Cancer Tsai , L., Bommakanti , S., Kapula , N., Satoyoshi , M., Aboujudom , C., Elliott , I., Guenthart , B., Liou , D., Lui , N., Backhus , L., Shrager , J., Berry , M. JTCVS Open. 2025
• Understanding the long-term impact of the COVID-19 pandemic on non-muscle-invasive bladder cancer outcomes: 12-Month follow-up data from the international, prospective COVIDSurg Cancer study. BJUI compass Alexander, C. E., Nathan, A., Light, A., Gao, C., Chan, V., Khadhouri, S., Gallagher, K., Byrnes, K. G., Walters, M., Hughes, T., Perry, R., Okoth, K., Magill, L., Pinkney, T., John, J. B., McGrath, J. S., Colquhoun, A., Zhang, Y., Blackmur, J., Etchill, E., Tang, S., García Escudero, D., Stewart, G., Kasivisvanathan, V. 2024; 5 (11): 1044-1051

  Abstract

  The objective of this study was to report the 12-month oncological outcomes for patients with non-muscle-invasive bladder cancer (NMIBC) within the prospective, international COVIDSurg Cancer study.Eligible patients were aged ≥18 years and scheduled for elective surgical management of NMIBC with curative intent (transurethral resection of bladder tumour [TURBT] or bladder biopsy) from 21 January to 14 April 2020. The primary outcome was disease recurrence within 12 months of previous elective TURBT/bladder biopsy. Secondary outcomes included disease progression within 12 months of previous elective TURBT/bladder biopsy, site-declared delay to surgery from diagnosis as a consequence of COVID-19 and deviation in standard care due to COVID-19. Comparisons were made to cohorts from the pre-pandemic era.Bladder cancer accounted for 2.2% (n = 446) of patients in the COVIDSurg Cancer study, with data contributed by 27 centres across 12 countries internationally. Within this included cohort, 229 patients had NMIBC and 12-month follow-up data available. On application of National Institute for Health and Care Excellence (NICE) criteria, 47.2% were classified as having high-risk disease. Overall disease recurrence and progression rates were 29.3% and 9.7% at 12 months, respectively. In purely high-risk pre-pandemic cohorts, the International Bladder Cancer Group (IBCG) estimates a recurrence rate of 25% at 12 months, and the European Association of Urology (EAU) NMIBC 2021 scoring model estimates a 12-month progression rate of 3.5%. As a consequence of the COVID-19 pandemic, 10.9% of patients had site-declared delay to TURBT/bladder biopsy; 7.4% did not undergo intravesical therapy or had early discontinuation of this; 9.2% did not undergo early repeat resection for high-risk disease; and 18.3% had a delay to cystoscopic follow-up surveillance.This prospective study indicates that there were widespread deviations in usual care for NMIBC during the pandemic and that 12-month oncological outcomes appear to be impaired compared to published pre-pandemic outcomes.

  View details for DOI 10.1002/bco2.432

  View details for PubMedID 39539562

  View details for PubMedCentralID PMC11557269

• Decreased Lung Metastasis in Triple Negative Breast Cancer Following Locally Delivered Supratherapeutic Paclitaxel-Loaded Polyglycerol Carbonate Nanoparticle Therapy. Biomacromolecules Sabatelle, R. C., Chu, N. Q., Blessing, W., Kharroubi, H., Bressler, E., Tsai, L., Shih, A., Grinstaff, M. W., Colson, Y. 2024; 25 (3): 1800-1809

  Abstract

  Breast cancer is among the most prevalent malignancies, accounting for 685,000 deaths worldwide in 2020, largely due to its high metastatic potential. Depending on the stage and tumor characteristics, treatment involves surgery, chemotherapy, targeted biologics, and/or radiation therapy. However, current treatments are insufficient for treating or preventing metastatic disease. Herein, we describe supratherapeutic paclitaxel-loaded nanoparticles (81 wt % paclitaxel) to treat the primary tumor and reduce the risk of subsequent metastatic lesions in the lungs. Primary tumor volume and lung metastasis are reduced by day 30, compared to the paclitaxel clinical standard treatment. The ultrahigh levels of paclitaxel afford an immunotherapeutic effect, increasing natural killer cell activation and decreasing NETosis in the lung, which limits the formation of metastatic lesions.

  View details for DOI 10.1021/acs.biomac.3c01258

  View details for PubMedID 38380618

  View details for PubMedCentralID PMC11331584

• Exclusion of a Giant Right Coronary Artery Aneurysm with Concomitant Bypass Grafting International Journal of Cardiovascular and Thoracic Surgery Mullis , D., Alnasir, D., Garrison , A., N, V., LL, T. 2024
• Automatic 1-year follow-up appointment creation and reminders can improve long-term follow-up after carotid revascularization AMERICAN JOURNAL OF SURGERY Stonko, D. P., Mohammed, S., Skojec, D., Rutkowski, J., Call, D., Verdi, K. G., Tsai, L. L., Black III, J. H., Perler, B. A., Abularrage, C. J., Lum, Y., Salameh, M. J., Hicks, C. W. 2024; 227: 57-62

  Abstract

  Long-term follow-up (LTFU) following carotid revascularization is important for post-surgical care, stroke risk optimization and post-market surveillance of new technologies.We instituted a quality improvement project to improve LTFU rates for carotid revascularizations (primary outcome) by scheduling perioperative and one-year follow-up appointments at time of surgery discharge. A temporal trends analysis (Q1 2019 through Q1 2022), multivariable regression, and interrupted time series (ITS) were performed to compare pre-post intervention LTFU rates.269 consecutive patients were included (151 pre-intervention, 118 post-intervention; mean 71 ​± ​12 years-old, 39% female, 77% White). The overall LTFU rate improved (64.9%-78.8%; P ​= ​0.013) after the intervention. After controlling for patient factors, procedures performed after the intervention were associated with increased odds of being seen for 1-year follow-up (OR: 2.2 95%CI: 1.2-4.0). Quarterly ITS analysis corroborated this relationship (P ​= ​0.01).Time-of-surgery appointment creation and automated patient reminders can improve LTFU rates following carotid revascularizations.

  View details for DOI 10.1016/j.amjsurg.2023.09.032

  View details for Web of Science ID 001135677700001

  View details for PubMedID 37827870

  View details for PubMedCentralID PMC10797636

• A dedicated robotic bedside physician assistant significantly enhances trainee console operating time in general thoracic surgery. JTCVS open Jones, B. T., Ha, J. S., Lawrence, C., Tsai, L. L., Yang, S. C. 2023; 16: 1070-1073

  Abstract

  As trainees rotate through thoracic subspecialties within their curricula, a crucial portion of their robotic training consists of actual console operating time. The more time spent on the surgeon console, the greater the development will be through the course of their training. Implementing a physician assistant at the bedside may increase the operative console time for the trainee and develop robotic skills in a more expeditious rate. The objective was to evaluate the impact a designated robotic physician assistant can have on trainee console learning opportunity.Operating room data collected consisted of all robotic general thoracic surgical cases that trainees participated in with and without a physician assistant present. Metrics regarding case efficiency included anesthesia ready-to-incision, incision-to-console, and raw resident console times. By using PRISM software, a nonparametric t test was used to analyze each averaged data group compared between when a physician assistant was present and not present.The mean resident console time without and with a physician assistant assist was 45.8 minutes and 80.9 minutes, respectively (P < .0001). The average portion of a case performed by a trainee similarly without and with a physician assistant present was 28.0% and 77.1%, respectively (P < .0001). Case efficiency metrics between physician assistant presence cohorts showed no difference.Thoracic surgical trainees have increased opportunity for robotic skill development within a fellowship or resident program curriculum when a designated robotic physician assistant is present in the operating room. These findings are significant for the improvement of residency and fellowship robotic training models moving forward by incorporating robotic-specialized physician assistants in academic institutions.

  View details for DOI 10.1016/j.xjon.2023.08.024

  View details for PubMedID 38204653

  View details for PubMedCentralID PMC10775067

• First-in-Human Intrathoracic Implantation of Multidrug-Eluting Microdevices for In Situ Chemotherapeutic Sensitivity Testing as Proof of Concept in Nonsmall Cell Lung Cancer. Annals of surgery Tsai, L. L., Phillips, W. W., Hung, Y. P., Dominas, C., Deans, K., Ahn, S., Ferland, B., Weiss, K., Lanuti, M., Auchincloss, H., Schumacher, L., Jonas, O., Colson, Y. L. 2023; 277 (5): e1143-e1149

  Abstract

  To evaluate the safety and feasibility of implantation and retrieval of a novel implantable microdevice (IMD) in NSCLC patients undergoing operative resection.Adjuvant therapy has limited impact on postsurgical outcomes in NSCLC due to the inability to predict optimal treatment regimens.An IMD measuring 6.5 mm by 0.7 mm, containing micro-reservoirs allowing for high-throughput localized drug delivery, was developed and loaded with 12 chemotherapeutic agents. Five patients with peripheral lung lesions larger than 1.0 cm were enrolled in this phase 1 clinical study. IMDs were inserted into tumors intraoperatively under direct vision, removed with the resected specimen, and retrieved in pathology. Surrounding tissues were sectioned, stained, and analyzed for tissue drug response to the IMD-delivered microdoses of these agents by a variety of pharmacodynamic markers.A total of 14 IMDs were implanted intraoperatively with 13 (93%) successfully retrieved. After technique refinement, IMDs were reliably inserted and retrieved in open, Video-Assisted Thoracoscopic Surgery, and robotic cases. No severe adverse reactions were observed. The one retained IMD has remained in place without movement or any adverse effects. Analysis of patient blood revealed no detection of chemotherapeutic agents. We observed differential sensitivities of patient tumors to the drugs on the IMD.A multi-drug IMD can be safely inserted and retrieved into lung tumors during a variety of surgical approaches. Future studies will encompass preoperative placement to better examine specific tumor responsiveness to therapeutic agents, allowing clinicians to tailor treatment regimens to the microenvironment of each patient.

  View details for DOI 10.1097/SLA.0000000000005385

  View details for PubMedID 35129472

• Midterm outcomes of isolated thoracic aortic replacement in congenital versus degenerative aortopathy in a 15-year institutional cohort. Journal of vascular surgery Sorber, R., Tsai, L. L., Hicks, C. W., Black, J. H. 2023; 77 (1): 20-27

  Abstract

  Open aortic replacement represents the only approved option to address thoracic aortopathy among patients with connective tissue disorders (CTD). The aim of our study was to investigate contemporary midterm outcomes of isolated thoracic aortic replacement in patients with CTD versus degenerative pathology in a large institutional cohort.All patients undergoing isolated open thoracic aortic replacement at a single academic center from 2005 to 2020 were included. Patients were classified as having CTD or not having CTD based on documented genetic mutations associated with congenital aortopathy. In-hospital and midterm outcomes, including mortality, paraplegia, development of new arterial pathology on surveillance imaging, and the need for future operations, were compared between groups using descriptive statistics and Kaplan-Meier survival analysis.Overall, 62 patients were included with a median follow-up of 58 months (range, 19-81 months) (59 months for those with CTD vs 51.5 months for those without CTD). CTD was present in 18 patients (29%), with 16 having Marfan syndrome (77.8%). Patients with CTD were younger than patients without CTD (45.8 years vs 60.9 years) and had lower rates of smoking (5.6% vs 56.8%) and hypertension (97.7% vs 72.2%; all P < .01). Patients with CTD were more likely to have a dissection component at the time of repair compared with patients without CTD (100% vs 59.1%) and underwent repair at smaller aortic diameters (5.9 cm vs 6.6 cm; both P < .05). There were no differences in in-hospital outcomes between the two groups, including mortality (4.5% vs 5.6%) and paraplegia (2.3% vs 0%; both P > .05). At 5 years, patients with CTD were more likely to have developed aneurysmal changes distal to their thoracic repair (88.9% vs 47.7%) and extra-aortic arterial aneurysms (41.2% vs 2.3%; both P < .05). However, on survival analysis, there were no differences in freedom from additional vascular procedures (hazard ratio,1.76; P = .333) or, specifically, additional aortic procedures (hazard ratio, 1.81; P = .380) between the two groups. There was only one anastomotic complication identified on longitudinal follow-up, which occurred in a patient without CTD 8 years after the index operation.Although carrying significant operative risks and the potential for morbidity, open thoracic aortic replacement represents a well-tolerated, durable treatment option for patients with congenitally mediated thoracic aortic disease. Because both patients with and without CTD who required thoracic aortic replacement often need future aortic intervention, vigilant surveillance is warranted. Equivalent intervention rates between the two groups suggest remodeling of the CTD aorta is almost universally characterized by initial postrepair dilation, but the majority of these changes successfully stabilize and do not progress to higher rates of intervention.

  View details for DOI 10.1016/j.jvs.2022.05.033

  View details for PubMedID 36055553

  View details for PubMedCentralID PMC9884488

• Commentary: Mentorship based on authentic connection. The Journal of thoracic and cardiovascular surgery Tsai, L. L., Ha, J. S. 2023; 165 (1): 406-407

  View details for DOI 10.1016/j.jtcvs.2021.11.032

  View details for PubMedID 34872763

• Lung Cancer in Women. The Annals of thoracic surgery Tsai, L. L., Chu, N. Q., Blessing, W. A., Moonsamy, P., Colson, Y. L. 2022; 114 (5): 1965-1973

  Abstract

  Lung cancer is the leading cause of cancer-related death for women in the United States. Clinical characteristics, histology, epidemiology, and treatment responses are unique for women with lung cancer.A literature search of Medline publications from 1989 to 2021 was conducted for lung cancer in women. Subsequent narrative review focused on identified differences in risk factors, diagnosis, and treatment of importance to the surgical care of these patients.Studies investigating lung cancer in which sex differences were explored demonstrated differences in risk factors, histology, and treatment response among women, with a significant postsurgical survival advantage over men (41.8 months vs 26.8 months, P = .007) and greater clinical benefit from anti-PD-1 combined with chemotherapy (hazard ratio, 0.44; 95% confidence interval, 0.25-0.76) compared with men (hazard ratio, 0.76; 95% confidence interval, 0.64-0.91). Smoking remains a dominant risk factor, and multiple clinical trials suggest lung cancer screening provides greater benefit for women. However young nonsmoking patients with lung cancer are 2-fold more likely to be female, advocating for broader sex-based screening criteria. Potential roles of genetic mutations, estrogen signaling, and infectious elements in sex-based differences in presentation, histology, prognosis, and treatment response are explored.Overall much remains unknown regarding how sex influences lung cancer risk, treatment decisions, and outcomes. However evidence of specific differences in presentation, environmental risk, molecular drivers, and mutational burden support the need to better leverage these sex-associated differences to further improve detection, diagnosis, surgical outcomes, and systemic regimens to advance the overall care strategy for women with lung cancer.

  View details for DOI 10.1016/j.athoracsur.2021.09.060

  View details for PubMedID 34742731

• Commentary: Reducing Resection of Benign Pulmonary Nodules - A Laudable Goal, but How and at What Cost? Seminars in thoracic and cardiovascular surgery Tsai, L. L., Broderick, S. R. 2022; 34 (3): 1100-1101

  View details for DOI 10.1053/j.semtcvs.2021.08.024

  View details for PubMedID 34481047

• The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2022; 24 (6): 708-26

  Abstract

  The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery.This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin.Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes.One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease.

  View details for DOI 10.1111/codi.16117

  View details for PubMedID 35286766

  View details for PubMedCentralID PMC9322431

• Porous Paclitaxel Mesh Reduces Local Recurrence in Patient-Derived Xenograft Resection Model Tsai , L., Fitzgerald , D., Liu, R., Korunes-Miller , J., Neal , E., Hung , Y., Bilton, S., Haha, A., Grinstaff, M., Colson , Y. Annals of Thoracic Surgery. 2022
• The Translational and Regulatory Development of an Implantable Microdevice for Multiple Drug Sensitivity Measurements in Cancer Patients. IEEE transactions on bio-medical engineering Dominas, C., Bhagavatula, S., Stover, E., Deans, K., Larocca, C., Colson, Y., Peruzzi, P., Kibel, A., Hata, N., Tsai, L., Hung, Y., Packard, R., Jonas, O. 2022; 69 (1): 412-421

  Abstract

  The purpose of this article is to report the translational process of an implantable microdevice platform with an emphasis on the technical and engineering adaptations for patient use, regulatory advances, and successful integration into clinical workflow.We developed design adaptations for implantation and retrieval, established ongoing monitoring and testing, and facilitated regulatory advances that enabled the administration and examination of a large set of cancer therapies simultaneously in individual patients.Six applications for oncology studies have successfully proceeded to patient trials, with future applications in progress.First-in-human translation required engineering design changes to enable implantation and retrieval that fit with existing clinical workflows, a regulatory strategy that enabled both delivery and response measurement of up to 20 agents in a single patient, and establishment of novel testing and quality control processes for a drug/device combination product without clear precedents.This manuscript provides a real-world account and roadmap on how to advance from animal proof-of-concept into the clinic, confronting the question of how to use research to benefit patients.

  View details for DOI 10.1109/TBME.2021.3096126

  View details for PubMedID 34242160

  View details for PubMedCentralID PMC8702455

• Machine learning risk prediction of mortality for patients undergoing surgery with perioperative SARS-CoV-2: the COVIDSurg mortality score. The British journal of surgery 2021; 108 (11): 1274-1292

  Abstract

  To support the global restart of elective surgery, data from an international prospective cohort study of 8492 patients (69 countries) was analysed using artificial intelligence (machine learning techniques) to develop a predictive score for mortality in surgical patients with SARS-CoV-2. We found that patient rather than operation factors were the best predictors and used these to create the COVIDsurg Mortality Score (https://covidsurgrisk.app). Our data demonstrates that it is safe to restart a wide range of surgical services for selected patients.

  View details for DOI 10.1093/bjs/znab183

  View details for PubMedID 34227657

  View details for PubMedCentralID PMC8344569

• Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study. The Lancet. Oncology 2021; 22 (11): 1507-1517

  Abstract

  Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20-60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16-30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77-0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50-0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80-0·88; p<0·001), and full lockdowns (0·57, 0·54-0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays.Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services.National Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

  View details for DOI 10.1016/S1470-2045(21)00493-9

  View details for PubMedID 34624250

  View details for PubMedCentralID PMC8492020

• Head and neck cancer surgery during the COVID-19 pandemic: An international, multicenter, observational cohort study. Cancer 2021; 127 (14): 2476-2488

  Abstract

  The aims of this study were to provide data on the safety of head and neck cancer surgery currently being undertaken during the coronavirus disease 2019 (COVID-19) pandemic.This international, observational cohort study comprised 1137 consecutive patients with head and neck cancer undergoing primary surgery with curative intent in 26 countries. Factors associated with severe pulmonary complications in COVID-19-positive patients and infections in the surgical team were determined by univariate analysis.Among the 1137 patients, the commonest sites were the oral cavity (38%) and the thyroid (21%). For oropharynx and larynx tumors, nonsurgical therapy was favored in most cases. There was evidence of surgical de-escalation of neck management and reconstruction. Overall 30-day mortality was 1.2%. Twenty-nine patients (3%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within 30 days of surgery; 13 of these patients (44.8%) developed severe respiratory complications, and 3.51 (10.3%) died. There were significant correlations with an advanced tumor stage and admission to critical care. Members of the surgical team tested positive within 30 days of surgery in 40 cases (3%). There were significant associations with operations in which the patients also tested positive for SARS-CoV-2 within 30 days, with a high community incidence of SARS-CoV-2, with screened patients, with oral tumor sites, and with tracheostomy.Head and neck cancer surgery in the COVID-19 era appears safe even when surgery is prolonged and complex. The overlap in COVID-19 between patients and members of the surgical team raises the suspicion of failures in cross-infection measures or the use of personal protective equipment.Head and neck surgery is safe for patients during the coronavirus disease 2019 pandemic even when it is lengthy and complex. This is significant because concerns over patient safety raised in many guidelines appear not to be reflected by outcomes, even for those who have other serious illnesses or require complex reconstructions. Patients subjected to suboptimal or nonstandard treatments should be carefully followed up to optimize their cancer outcomes. The overlap between patients and surgeons testing positive for severe acute respiratory syndrome coronavirus 2 is notable and emphasizes the need for fastidious cross-infection controls and effective personal protective equipment.

  View details for DOI 10.1002/cncr.33320

  View details for PubMedID 33345297

• Delivery of eupenifeldin via polymer-coated surgical buttresses prevents local lung cancer recurrence. Journal of controlled release : official journal of the Controlled Release Society Al Subeh, Z. Y., Chu, N. Q., Korunes-Miller, J. T., Tsai, L. L., Graf, T. N., Hung, Y. P., Pearce, C. J., Grinstaff, M. W., Colby, A. H., Colson, Y. L., Oberlies, N. H. 2021; 331: 260-269

  Abstract

  Lung cancer is the leading cause of cancer deaths worldwide. Unfortunately, high recurrence rates and poor survival remain despite surgical resection and conventional chemotherapy. Local drug delivery systems are a promising intervention for lung cancer treatment with the potential for improved efficacy with reduced systemic toxicity. Here, we describe the development of a chemotherapy-loaded polymer buttress, to be implanted along the surgical margin at the time of tumor resection, for achieving local and prolonged release of a new anticancer agent, eupenifeldin. We prepared five different formulations of buttresses with varying amounts of eupenifeldin, and additional external empty polymer coating layers (or thicknesses) to modulate drug release. The in vitro eupenifeldin release profile depends on the number of external coating layers with the formulation of the greatest thickness demonstrating a prolonged release approaching 90 days. Similarly, the long-term cytotoxicity of eupenifeldin-loaded buttress formulations against murine Lewis lung carcinoma (LLC) and human lung carcinoma (A549) cell lines mirrors the eupenifeldin release profiles and shows a prolonged cytotoxic effect. Eupenifeldin-loaded buttresses significantly decrease local tumor recurrence in vivo and increase disease-free survival in a lung cancer resection model.

  View details for DOI 10.1016/j.jconrel.2021.01.026

  View details for PubMedID 33484778

  View details for PubMedCentralID PMC7946725

• Preoperative nasopharyngeal swab testing and postoperative pulmonary complications in patients undergoing elective surgery during the SARS-CoV-2 pandemic BRITISH JOURNAL OF SURGERY Glasbey, J. C., Omar, O., Nepogodiev, D., Minaya-Bravo, A., Bankhead-Kendall, B., Fiore, M., Futaba, K., Gabre-Kidan, A., Gujjuri, R. R., Isik, A., Kaafarani, H. M. A., Kamarajah, S. K., Li, E., Loeffler, M. W., McLean, K. A., Outani, O., Ntirenganya, F., Satoi, S., Shaw, R., Simoes, J. F. F., Stewart, G. D., Tabiri, S., Trout, I. M., Bhangu, A. A., Glasbey, J. C., Omar, O., Bhangu, A. A., Siaw-Acheampong, K., Benson, R. A., Bywater, E., Chaudhry, D., Dawson, B. E., Evans, J. P., Glasbey, J. C., Gujjuri, R. R., Heritage, E., Jones, C. S., Kamarajah, S. K., Khatri, C., Khaw, R. A., Keatley, J. M., Knight, A., Lawday, S., Li, E., Mann, H. S., Marson, E. J., McLean, K. A., Mckay, S. C., Mills, E. C., Nepogodiev, D., Pellino, G., Picciochi, M., Taylor, E. H., Tiwari, A., Simoes, J. F. F., Trout, I. 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T., Carannante, F., Caricato, M., Masciana, G., Mazzotta, E., Gattolin, A., Migliore, M., Rimonda, R., Sasia, D., Travaglio, E., Cervellera, M., Gori, A., Sartarelli, L., Tonini, Giacometti, M., Zonta, S., Chessa, A., Fiorini, A., Norcini, C., Colletti, G., Confalonieri, M., Costanzi, A., Frattaruolo, C., Mari, G., Monteleone, M., Bandiera, A., Bocciolone, L., Bonavina, G., Candiani, M., Candotti, G., De Nardi, P., Gagliardi, F., Medone, M., Mortini, P., Negri, G., Parise, P., Piloni, M., Sileri, P., Vignali, A., Belvedere, A., Bernante, P., Bertoglio, P., Boussedra, S., Brunocilla, E., Cipriani, R., Cisternino, G., De Crescenzo, E., De Iaco, P., Dondi, G., Frio, F., Jovine, E., Bianchi, M. F., Neri, J., Parlanti, D., Perrone, A. M., Pezzuto, A. P., Pignatti, M., Pinto, Poggioli, G., Ravaioli, M., Rottoli, M., Schiavina, R., Serenari, M., Serra, M., Solli, P., Taffurelli, M., Tanzanu, M., Tesei, M., Violante, T., Zanotti, S., Borghi, F., Cianflocca, D., Grimaldi, D. 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T., Burgan, D., Kamoka, E., Kilani, A., Salamah, A., Salem, M., Shuwayyah, A., Abdulwahed, E., Alshareea, E., Aribi, N., Aribi, S., Biala, M., Ghamgh, R., Morgom, M., Aldayri, Z., Ellojli, Kredan, A., Bradulskis, S., Dainius, E., Kubiliute, E., Kutkevicius, J., Parseliunas, A., Subocius, A., Venskutonis, D., Rasoaherinomenjanahary, F., Razafindrahita, J. B., Samison, L. H., Ong, E. C., Hamdan, K. H., Ibrahim, M. R., Tan, J. A., Thanapal, M. R., Sahid, A. N., Hayati, F., Jayasilan, J., Sriram, R. K., Subramaniam, S., Jusoh, C. A., Hussain, A. H., Sidek, M. A. S., Yunus, M. M. F., Soh, J. Y., Wong, M. K., Zakaria, A. D., Zakaria, Z., Fadzli, A., Fathi, N. Q., Koh, P. S., Liew, Y. T., Roslani, A. C., Tang, C. Y., Teoh, L. Y., Wong, W. J., Yahaya, A. S., Alvarez, M. R., Arrangoiz, R., Cordera, F., De la Rosa Abaroa, M. A., Gomez-Pedraza, A., Hernandez, R., Maffuz-Aziz, A., Posada, J. A., Becerra Garcia, F. C., Alfaro-Goldaracena, A., Buerba, G. A., Castillejos-Molina, R. 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M., Abdelrahman, S., Althobaiti, W., Al Habes, H., Alamri, A., Alkarak, S., Alqannas, M., Alyami, M., Alzamanan, M., Guiral, C. D., Elawad, A., AlAamer, O., Alriyees, L., Alselaim, N., Abdulkareem, A., Ajlan, A., Akkour, K., Al-Habib, A., Al-Khayal, K., Alatar, A., Alburakan, A., Alhalal, H., Alhassan, B., Alhassan, N., Alobeed, O., Alsaif, A., Alsaif, F., Alshammari, S., Alshaygy, Barry, M., Bin Nasser, A., Bin Traiki, T., Bokhari, A., Elwatidy, S., Helmi, H., Madkhali, A., Nouh, T., Rabah, P. D., Zubaidi, A., Paunovic, Slijepcevic, N., Aleksic, L., Antic, A., Barisic, G., Ceranic, M., Galun, D., Grubac, Z., Jelenkovic, J., Kecmanovic, D., Kmezic, S., Knezevic, D., Krivokapic, Z., Latincic, S., Markovic, Matic, S., Miladinov, M., Pavlov, M., Pejovic, Radenkovic, D., Tadic, B., Vasljevic, J., Velickovic, D., Zivanovic, M., Perovic, M., Srbinovic, L., Andrijasevic, S., Bozanovic, T., Popovic, C. R., Dokic, M., Janjic, T., Jeremic, K., Kadija, S., Likic, L., Mirkovic, L., Pantovic, S., Pilic, Radojevic, M., Stefanovic, A., Vidakovic, S., Vilendecic, Z., Antic, S., Dunderovic, D., Jelovac, D., Jezdic, Z., Konstantinovic, Kotlar, B., Kuzmanovic, C., Lazic, M., Petrovic, M., Popovic, F., Pucar, A., Romic, M., Sumrak, S., Vujanac, V., Bascarevic, Bogdanovic, Grujicic, D., Ilic, R., Milicevic, M., Milisavljevic, F., Miljkovic, A., Paunovic, A., Scepanovic, Stanimirovic, A., Todorovic, M., Jotic, A., Milovanovic, J., Trivic, A., Bumbasirevic, U., Dzamic, Z., Kajmakovic, B., Prijovic, N., Zivkovic, M., Buta, M., Cvetkovic, A., Djurisic, Gacic, S., Goran, M., Inic, Z., Jeftic, N., Jevric, M., Jokic, Markovic, Milanovic, M., Nikolic, S., Pejnovic, L., Savkovic, N., Spurnic, Stevic, D., Stojiljkovic, D., Vucic, N., Zegarac, M., Karamarkovic, A., Kenic, M., Kovacevic, B., Krdzic, Milutinovic, Chan, C. 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E., Torales, J., Torne, A., Torne, R., Turrado-Rodriguez, Valero, R., Valverde, S., Anula, R., Cano-Valderrama, O., Del Campo Martin, M., Diez-Valladares, L., Dominguez, Dziakova, J., Garcia Alonso, M., Garcia Romero, E., Gomez Latorre, L., Muguerza, J. M., Pizarro, M. J., Saez Carlin, P., Sanchez del Pueblo, C., Sanchez-Pernaute, A., Sanz Ortega, G., Sanz-Lopez, R., Torres, A., Garces-Albir, M., Lopez, F., Martin-Arevalo, J., Moro-Valdezate, D., Pla-Marti, Beltran de Heredia, J., De Andres Asenjo, B., Gomez Sanz, T., Jezieniecki, C., Nunez Del Barrio, H., de Solorzano Aurusa, O. F. J., Romero de Diego, A., Ruiz Soriano, M., Trujillo Diaz, J., Vazquez Fernandez, A., Lora-Cumplido, P., Sosa, M., Gonzalez-Gonzalez, E., Minaya Bravo, A. M., Alonso de la Fuente, N., Cazador Labat, M., Cecchini, L., Espinosa, C. A., Jimenez Toscano, M., Lopez Campillo, A., Mancebo, G., Martorell, P., Munarriz, M., Grau-Talens, E. J., Martin-Perez, B., Benavides Buleje, J. 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P., Salinas Pena, J., Aragon Achig, E. J., Barbier, L., Caja Vivancos, P., Gainza, A., Garcia Gutierrez, J. J., Mallabiabarrena Ormaechea, G., Marin, H., Martin Playa, P., Melchor Corcostegui, Prieto Calvo, M., Rodriguez Fraga, A., Villalabeitia Ateca, De Andres Olabarria, U., Duran Ballesteros, M., Fernandez Pablos, F. J., Ibanez-Aguirre, F. J., Sanz Larrainzar, A., Ugarte-Sierra, B., De la Hoz Rodriguez, A., Di Martino, M., Garcia Septiem, J., Martin-Perez, E., Munoz de Nova, J. L., Calvo Espino, P., Guillamot Ruano, P., Colao Garcia, L., Diaz Perez, D., Esteban Agusti, E., Galindo Jara, P., Gutierrez Samaniego, M., Hernandez Bartolome, M. A., Serrano Gonzalez, J., Alonso Poza, A., Dieguez, B., Garcia-Conde, M., Hernandez-Garcia, M., Losada, M., Chiesa-Estomba, C. M., Gonzalez Garcia, J. A., Larruscain, E., Sistiaga-Suarez, J. 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  Abstract

  Surgical services are preparing to scale up in areas affected by COVID-19. This study aimed to evaluate the association between preoperative SARS-CoV-2 testing and postoperative pulmonary complications in patients undergoing elective cancer surgery.This international cohort study included adult patients undergoing elective surgery for cancer in areas affected by SARS-CoV-2 up to 19 April 2020. Patients suspected of SARS-CoV-2 infection before operation were excluded. The primary outcome measure was postoperative pulmonary complications at 30 days after surgery. Preoperative testing strategies were adjusted for confounding using mixed-effects models.Of 8784 patients (432 hospitals, 53 countries), 2303 patients (26.2 per cent) underwent preoperative testing: 1458 (16.6 per cent) had a swab test, 521 (5.9 per cent) CT only, and 324 (3.7 per cent) swab and CT. Pulmonary complications occurred in 3.9 per cent, whereas SARS-CoV-2 infection was confirmed in 2.6 per cent. After risk adjustment, having at least one negative preoperative nasopharyngeal swab test (adjusted odds ratio 0.68, 95 per cent confidence interval 0.68 to 0.98; P = 0.040) was associated with a lower rate of pulmonary complications. Swab testing was beneficial before major surgery and in areas with a high 14-day SARS-CoV-2 case notification rate, but not before minor surgery or in low-risk areas. To prevent one pulmonary complication, the number needed to swab test before major or minor surgery was 18 and 48 respectively in high-risk areas, and 73 and 387 in low-risk areas.Preoperative nasopharyngeal swab testing was beneficial before major surgery and in high SARS-CoV-2 risk areas. There was no proven benefit of swab testing before minor surgery in low-risk areas.

  View details for DOI 10.1093/bjs/znaa051

  View details for Web of Science ID 000637023600048

  View details for PubMedID 33640908

  View details for PubMedCentralID PMC7717156

• Chapter 89: Acute Pancreatitis Tsai , L., Lipsett, . Vincent Textbook of Critical Care 8e. 2021
• Chapter 45: Systemic Complications: Respiratory Tsai , L., Lipsett , P. Rutherford Vascular and Endovascular Therapy 10e. 2021
• Asian Americans in Academic Surgery Tsai , L., Ha , J., Yang , S. Annals of Surgery. 2021
• Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology Glasbey, J. C., Nepogodiev, D., Simoes, J. F., Omar, O., Li, E., Venn, M. L., , Abou Chaar, M. K., Capizzi, V., Chaudhry, D., Desai, A., Edwards, J. G., Evans, J. P., Fiore, M., Videria, J. F., Ford, S. J., Ganly, I., Griffiths, E. A., Gujjuri, R. R., Kolias, A. G., Kaafarani, H. M., Minaya-Bravo, A., McKay, S. C., Mohan, H. M., Roberts, K. J., San Miguel-Méndez, C., Pockney, P., Shaw, R., Smart, N. J., Stewart, G. D., Sundar Mrcog, S., Vidya, R., Bhangu, A. A. 2021; 39 (1): 66-78

  Abstract

  As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway.This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation).Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76).Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks.

  View details for DOI 10.1200/JCO.20.01933

  View details for PubMedID 33021869

  View details for PubMedCentralID PMC8189635

• Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020; 23 (3): 732-49

  Abstract

  This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic.This was an international cohort study of patients undergoing elective resection of colon or rectal cancer without preoperative suspicion of SARS-CoV-2. Centres entered data from their first recorded case of COVID-19 until 19 April 2020. The primary outcome was 30-day mortality. Secondary outcomes included anastomotic leak, postoperative SARS-CoV-2 and a comparison with prepandemic European Society of Coloproctology cohort data.From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. Thirty-day mortality was 1.8% (38/2073), the incidence of postoperative SARS-CoV-2 was 3.8% (78/2073) and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS-CoV-2 (14/1601, 0.9%) and highest in patients with both a leak and SARS-CoV-2 (5/13, 38.5%). Mortality was independently associated with anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58-14.06), postoperative SARS-CoV-2 (16.90, 7.86-36.38), male sex (2.46, 1.01-5.93), age >70 years (2.87, 1.32-6.20) and advanced cancer stage (3.43, 1.16-10.21). Compared with prepandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%) and an overall shorter length of stay (6 versus 7 days) but higher mortality (1.7% versus 1.1%).Surgeons need to further mitigate against both SARS-CoV-2 and anastomotic leak when offering surgery during current and future COVID-19 waves based on patient, operative and organizational risks.

  View details for DOI 10.1111/codi.15431

  View details for PubMedID 33191669

  View details for PubMedCentralID PMC7753519

• Training of Male and Female Surgical Residents. JAMA surgery Sorber, R., Weaver, M. L., Tsai, L. L. 2020; 155 (10): 998

  View details for DOI 10.1001/jamasurg.2020.2430

  View details for PubMedID 32725181

• Should We Perform Carotid Doppler Screening Before Surgical or Transcatheter Aortic Valve Replacement? The Annals of thoracic surgery Condado, J. F., Jensen, H. A., Maini, A., Ko, Y. A., Rajaei, M. H., Tsai, L. L., Devireddy, C., Leshnower, B., Mavromatis, K., Sarin, E. L., Stewart, J., Guyton, R. A., Babaliaros, V., Chen, E. P., Halkos, M., Simone, A., Keegan, P., Block, P. C., Thourani, V. H. 2017; 103 (3): 787-794

  Abstract

  Screening for internal carotid artery stenosis (ICAS) with Doppler ultrasound is commonly used before cardiovascular surgery. Nevertheless, the relationship between ICAS and procedure-related stroke in isolated aortic valve replacement is unclear.We retrospectively reviewed patients with artery stenosis who underwent ICAS screening before surgical (SAVR) or transcatheter aortic valve replacement (TAVR) between January 2007 and August 2014. Logistic regression models were used to determine the relation between post-procedure stroke and total (sum of left and right ICAS) and maximal unilateral ICAS. Age, sex, history of atrial fibrillation, cerebrovascular disease and diabetes, left ventricular ejection fraction, and procedure type were considered as covariates. Two-subgroup analyses were performed in patients who underwent TAVR and SAVR, adjusting for procedure specific details.A total of 996 patients underwent ICAS screening before TAVR (n = 467) or SAVR (n = 529). The prevalence of at least ≥70% ICAS was 5.2% (n = 52) and incidence of 30-day stroke was 3.4% (n = 34). Eight patients who underwent carotid intervention before valve replacement and 6 patients with poor Doppler images were excluded from the final analysis. We found no statistically significant association between stroke and either the total or maximal unilateral ICAS for all patients (p = 0.13 and p = 0.39, respectively) or those undergoing TAVR (p = 0.27 and p = 0.63, respectively) or SAVR (p = 0.21 and p = 0.36, respectively).We found no statistically significant association between ICAS severity procedure-related stroke after aortic valve replacement. This suggests that universal carotid Doppler screening before isolated TAVR or SAVR is unnecessary.

  View details for DOI 10.1016/j.athoracsur.2016.06.076

  View details for PubMedID 27717427

• Does a Higher Society of Thoracic Surgeons Score Predict Outcomes in Transfemoral and Alternative Access Transcatheter Aortic Valve Replacement? The Annals of thoracic surgery Jensen, H. A., Thourani, V. H., Forcillo, J., Condado, J. F., Binongo, J. N., Babaliaros, V., Lasanajak, Y., Leshnower, B., Devireddy, C., Guyton, R., Mavromatis, K., Block, P., Simone, A., Keegan, P., Stewart, J., Tsai, L. L., Rajaei, M. H., Lerakis, S., Sarin, E. L. 2016; 102 (2): 474-82

  Abstract

  Nontransfemoral (non-TF) transcatheter aortic valve replacement (TAVR) is often associated with worse outcomes than TF TAVR. We investigated the relationship between increasing Society of Thoracic Surgeons (STS) predicted risk of mortality (PROM) score and observed mortality and morbidity in TF and non-TF TAVR groups.We reviewed 595 patients undergoing TAVR at Emory Healthcare between 2007 and 2014. Clinical outcomes were reported for 337 TF patients (57%) and 258 non-TF patients (43%). We created 3 STS PROM score subgroups: <8%, 8%-15%, and >15%. A composite outcome of postoperative events was defined as death, stroke, renal failure, vascular complications, or new pacemaker implantation.TF patients were older (82.4 ± 8.0 vs 80.8 ± 8.7 years, p = 0.02), whereas the STS PROM was higher in non-TF patients (10.5% ± 5.3% vs 11.7% ± 5.7%, p = 0.01). Observed/expected mortality was less than 1.0 in all groups. The rate of the composite outcome did not differ between STS PROM subgroups in TF (p = 0.68) or non-TF TAVR (p = 0.27). One-year mortality was higher for patients with STS PROM >8% in the non-TF group; however, this difference was not observed in TF patients (p = 0.40).As expected, non-TF patients were at a higher risk than TF patients for procedural morbidity and death. Although no differences were observed in 30-day deaths or morbidity in different STS PROM subgroups, those undergoing non-TF TAVR at a higher STS PROM (>8%) had higher 1-year mortality. When applicable, TF TAVR remains the procedure of choice in high- or extreme-risk patients undergoing TAVR.

  View details for DOI 10.1016/j.athoracsur.2016.02.020

  View details for PubMedID 27209615

• Intensive Glycemic Control in Cardiac Surgery. Current diabetes reports Tsai, L. L., Jensen, H. A., Thourani, V. H. 2016; 16 (4): 25

  Abstract

  Hyperglycemia has been found to be associated with increased morbidity and mortality in surgical patients, yet, the optimal glucose management strategy during the perioperative setting remains undetermined. While much has been published about hyperglycemia and cardiac surgery, most studies have used widely varying definitions of hyperglycemia, methods of insulin administration, and the timing of therapy. This has only allowed investigators to make general conclusions in this challenging clinical scenario. This review will introduce the basic pathophysiology of hyperglycemia in the cardiac surgery setting, describe the main clinical consequences of operative hyperglycemia, and take the reader through the published material of intensive and conservative glucose management. Overall, it seems that intensive control has modest benefits with adverse effects often outweighing these advantages. However, some studies have indicated differing results for certain patient subgroups, such as non-diabetics with acute operative hyperglycemia. Future studies should focus on distinguishing which patient populations, if any, would optimally benefit from intensive insulin therapy.

  View details for DOI 10.1007/s11892-016-0719-5

  View details for PubMedID 26879308

• Will transcatheter valve-in-valve become the standard for replacing the degenerative aortic valve bioprosthesis? Hold your horses, the jury is still out. The Journal of thoracic and cardiovascular surgery Forcillo, J., Tsai, L. L., Thourani, V. H. 2015; 150 (6): 1568-9

  View details for DOI 10.1016/j.jtcvs.2015.08.114

  View details for PubMedID 26421984

• Minimalist transcatheter aortic valve replacement: The new standard for surgeons and cardiologists using transfemoral access? The Journal of thoracic and cardiovascular surgery Jensen, H. A., Condado, J. F., Devireddy, C., Binongo, J., Leshnower, B. G., Babaliaros, V., Sarin, E. L., Lerakis, S., Guyton, R. A., Stewart, J. P., Syed, A. Q., Mavromatis, K., Kaebnick, B., Rajaei, M. H., Tsai, L. L., Rahman, A., Simone, A., Keegan, P., Block, P. C., Thourani, V. H. 2015; 150 (4): 833-9

  Abstract

  A minimalist approach for transcatheter aortic valve replacement (MA-TAVR) utilizing transfemoral access under conscious sedation and transthoracic echocardiography is increasing in popularity. This relatively novel technique may necessitate a learning period to achieve proficiency in performing a successful and safe procedure. This report evaluates our MA-TAVR cohort with specific characterization between our early, midterm, and recent experience.We retrospectively reviewed 151 consecutive patients who underwent MA-TAVR with surgeons and interventionists equally as primary operator at Emory University between May 2012 and July 2014. Our institution had performed 300 TAVR procedures before implementation of MA-TAVR. Patient characteristics and early outcomes were compared using Valve Academic Research Consortium 2 definitions among 3 groups: group 1 included the first 50 patients, group 2 included patients 51 to 100, and group 3 included patients 101 to 151.Median age for all patients was 84 years and similar among groups. The majority of patients were men (56%) and the median ejection fraction for all patients was 55% (interquartile range, 38.0%-60.0%). The majority of patients were high-risk surgical candidates with a median Society of Thoracic Surgeons Predicted Risk of Mortality of 10.0% and similar among groups. The overall major stroke rate was 3.3%, major vascular complications occurred in 3% of patients, and greater-than-mild paravalvular leak rate was 7%. In-hospital mortality and morbidity were similar among all 3 groups.In a high-volume TAVR center, transition to MA-TAVR is feasible with acceptable outcomes and a diminutive procedural learning curve. We advocate for TAVR centers to actively pursue the minimalist technique with equal representation by cardiologists and surgeons.

  View details for DOI 10.1016/j.jtcvs.2015.07.078

  View details for PubMedID 26318351

• The aged and the ill: A decade of surgical aortic valve replacement outcomes. The Journal of thoracic and cardiovascular surgery Tsai, L. L., Jensen, H. A., Thourani, V. H. 2015; 150 (3): 579-80

  View details for DOI 10.1016/j.jtcvs.2015.06.016

  View details for PubMedID 26149102

• The Heart and the Head: Neurological Implications of Transcatheter Aortic Valve Replacement. Journal of the American College of Cardiology Thourani, V. H., Tsai, L., Jensen, H. 2015; 66 (3): 218-220

  View details for DOI 10.1016/j.jacc.2015.06.001

  View details for PubMedID 26184613

• “A Couple Hours.” Tsai , L. Consortium of Universities for Global Health. Reflection and Global Health Education: An Anthology. 2015
• The use of transcatheter aortic valve replacement vs surgical aortic valve replacement for the treatment of aortic stenosis RESEARCH REPORTS IN CLINICAL CARDIOLOGY Jensen, H. A., Tsai, L. L., Thourani, V. H. 2015; 6: 105-116

  View details for DOI 10.2147/RRCC.S71379

  View details for Web of Science ID 000219063600011

• Identification of in vivo-induced bacterial proteins during human infection with Salmonella enterica serotype Paratyphi A. Clinical and vaccine immunology : CVI Alam, M. M., Tsai, L. L., Rollins, S. M., Sheikh, A., Khanam, F., Bufano, M. K., Yu, Y., Wu-Freeman, Y., Kalsy, A., Sultana, T., Sayeed, M. A., Jahan, N., LaRocque, R. C., Harris, J. B., Leung, D. T., Brooks, W. A., Calderwood, S. B., Charles, R. C., Qadri, F., Ryan, E. T. 2013; 20 (5): 712-9

  Abstract

  Salmonella enterica serotype Paratyphi A is a human-restricted pathogen and the cause of paratyphoid A fever. Using a high-throughput immunoscreening technique, in vivo-induced antigen technology (IVIAT), we identified 20 immunogenic bacterial proteins expressed in humans who were bacteremic with S. Paratyphi A but not those expressed in S. Paratyphi A grown under standard laboratory conditions. The majority of these proteins have known or potential roles in the pathogenesis of S. enterica. These include proteins implicated in cell adhesion, fimbrial structure, adaptation to atypical conditions, oxidoreductase activity, proteolysis, antimicrobial resistance, and ion transport. Of particular interest among these in vivo-expressed proteins were S. Paratyphi A (SPA)2397, SPA2612, and SPA1604. SPA2397 and SPA2612 are prophage related, and SPA1604 is in Salmonella pathogenicity island 11 (SPI-11). Using real-time quantitative PCR (RT-qPCR), we confirmed increased levels of mRNA expressed by genes identified by IVIAT in a comparison of mRNA levels in organisms in the blood of bacteremic patients to those in in vitro cultures. Comparing convalescent- to acute-phase samples, we also detected a significant increase in the reaction of convalescent-phase antibodies with two proteins identified by IVIAT: SPA2397 and SPA0489. SPA2397 is a phage-related lysozyme, Gp19, and SPA0489 encodes a protein containing NlpC/P60 and cysteine, histidine-dependent amidohydrolase/peptidase (CHAP) domains. In a previous study utilizing a different approach, we found that transcripts for 11 and 7 of the genes identified by IVIAT were detectable in organisms in the blood of humans in Bangladesh who were bacteremic with S. Paratyphi A and Salmonella enterica serovar Typhi, respectively. S. Paratyphi A antigens identified by IVIAT warrant further evaluation for their contributions to pathogenesis and might have diagnostic, therapeutic, or preventive relevance.

  View details for DOI 10.1128/CVI.00054-13

  View details for PubMedID 23486419

  View details for PubMedCentralID PMC3647755

• Identification of immunogenic Salmonella enterica serotype Typhi antigens expressed in chronic biliary carriers of S. Typhi in Kathmandu, Nepal Charles, R. PLoS Neglected Tropical Diseases . 2013