Monica M. Dua, MD

All Publications

• Postoperative outcomes and costs of laparoscopic versus robotic distal pancreatectomy: a propensity-matched analysis. Surgical endoscopy Timmerhuis, H. C., Jensen, C. W., Ngongoni, R. F., Baiocchi, M., DeLong, J. C., Ohkuma, R., Dua, M. M., Norton, J. A., Poultsides, G. A., Worth, P. J., Visser, B. C. 2024

  Abstract

  Minimally invasive distal pancreatectomy (MIDP) has established advantages over the open approach. The costs associated with robotic DP (RDP) versus laparoscopic DP (LDP) make the robotic approach controversial. We sought to compare outcomes and cost of LDP and RDP using propensity matching analysis at our institution.Patients undergoing LDP or RDP between 2000 and 2021 were retrospectively identified. Patients were optimally matched using age, gender, American Society of Anesthesiologists status, body mass index, and tumor size. Between-group differences were analyzed using the Wilcoxon signed-rank test for continuous data, and the McNemar's test for categorical data. Outcomes included operative duration, conversion to open surgery, postoperative length of stay, pancreatic fistula rate, pseudocyst requiring intervention, and costs.298 patients underwent MIDP, 180 (60%) were laparoscopic and 118 (40%) were robotic. All RDPs were matched 1:1 to a laparoscopic case with absolute standardized mean differences for all matching covariates below 0.10, except for tumor type (0.16). RDP had longer operative times (268 vs 178 min, p < 0.01), shorter length of stay (2 vs 4 days, p < 0.01), fewer biochemical pancreatic leaks (11.9% vs 34.7%, p < 0.01), and fewer interventional radiological drainage (0% vs 5.9%, p = 0.01). The number of pancreatic fistulas (11.9% vs 5.1%, p = 0.12), collections requiring antibiotics or intervention (11.9% vs 5.1%, p = 0.12), and conversion rates (3.4% vs 5.1%, p = 0.72) were comparable between the two groups. The total direct index admission costs for RDP were 1.01 times higher than for LDP for FY16-19 (p = 0.372), and 1.33 times higher for FY20-22 (p = 0.031).Although RDP required longer operative times than LDP, postoperative stays were shorter. The procedure cost of RDP was modestly more expensive than LDP, though this was partially offset by reduced hospital stay and reintervention rate.

  View details for DOI 10.1007/s00464-024-10728-8

  View details for PubMedID 38438677

  View details for PubMedCentralID 1877036

• Comparison of Spleen-Preservation Versus Splenectomy in Minimally Invasive Distal Pancreatectomy. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Timmerhuis, H. C., Ngongoni, R. F., Jensen, C. W., Baiocchi, M., DeLong, J. C., Dua, M. M., Norton, J. A., Poultsides, G. A., Worth, P. J., Visser, B. C. 2023

  Abstract

  Spleen-preservation during minimally invasive distal pancreatectomy (MIDP) can be technically challenging and remains controversial. Our primary aim was to compare MIDP and splenectomy with spleen-preserving MIDP. Secondarily, we compared two spleen-preserving techniques.Adults undergoing MIDP (2007-2021) were retrospectively included in this single-center study. Intraoperative and postoperative outcomes between spleen-preservation and splenectomy and between the two spleen-preserving techniques were compared using the Mann-Whitney U test for continuous data, and Fisher's exact test for categorical data.Of the 293 patients who underwent MIDP, preservation of the spleen was intended in 208 (71%) patients. Spleen-preservation was achieved in 174 patients (84%) via the Warshaw technique (130; 75%) or vessel-preservation (44; 25%). The spleen-preserving group had shorter length of stay (3 vs 4 days, p < 0.01), fewer conversions to open (1 vs 12, p < 0.01) and less blood loss (p < 0.01) compared to the splenectomy group. Operative (OR) times were comparable (229 vs 214 min, p = 0.67). Except for the operative time, which was longer for the Warshaw technique (245 vs 183 min, p = 0.01), no other differences between the two spleen-preserving techniques were found. At a median follow-up of 43 (IQR 18-79) months after spleen-preservation, only 2 (1.1%) patients had required splenectomy (1 partial splenectomy for infarct/abscess after Warshaw, 1 for variceal bleeding after vessel-preserving).Spleen-preservation is not associated with increased risk of blood loss, longer hospital stay, conversion, nor lengthy OR times. Late splenectomy is very rarely required. Given the immune consequences of splenectomy, spleen-preservation should be strongly considered in MIDP.

  View details for DOI 10.1007/s11605-023-05809-3

  View details for PubMedID 37653153

  View details for PubMedCentralID 3912973

• Correction: A Novel Fat-Augmented Omentum-Based Construct for Unilateral and Bilateral Free-Flap Breast Reconstruction in Underweight and Normal Weight Women Receiving Nipple or Skin-Sparing Mastectomies. Annals of surgical oncology Nguyen, D. H., Rochlin, D. H., Deptula, P. L., Zak, Y., Dua, M., Wapnir, I. L. 2023

  View details for DOI 10.1245/s10434-023-13720-z

  View details for PubMedID 37289269

• Going Virtual: Effect of Implementing Video Visits On Readmission Rates in Gi Surgical Oncology Patients DeLong, J. C., Ngongoni, R., Khan, S., Ohkuma, R., Timmerhuis, H., Dua, M. M., Visser, B. LIPPINCOTT WILLIAMS & WILKINS. 2023: S63-S64

  View details for Web of Science ID 000989943300167

• Single Cell Transcriptomic Analysis of Human Extra- and Intra-Hepatic Cholangiocarcinoma Ayala, C. I., Sathe, A., Grimes, S., Bae, X., Dua, M., Poultsides, G., Visser, B., Ji, H. SPRINGER. 2023: S177-S178

  View details for Web of Science ID 001046841200386

• Fragmentation of Gastroesophageal Junction Cancer Care in California Rejoice Ngongoni, F., Li, A. Y., Timmerhuis, H., Furst, A., Trickey, A., DeLong, J., Dua, M., Visser, B. SPRINGER. 2023: S151

  View details for Web of Science ID 001046841200322

• ASO Visual Abstract: A Novel Fat-Augmented Omentum-Based Construct for Unilateral and Bilateral Free Flap Breast Reconstruction in Underweight and Normal-Weight Women Receiving Nipple- or Skin-Sparing Mastectomies. Annals of surgical oncology Nguyen, D. H., Rochlin, D. H., Deptula, P. L., Zak, Y., Dua, M., Wapnir, I. L. 2023

  View details for DOI 10.1245/s10434-023-13208-w

  View details for PubMedID 36788187

• ASO Author Reflections: Innovation and the Development of a New Workhorse Flap in Breast Reconstruction. Annals of surgical oncology Nguyen, D. H., Rochlin, D. H., Deptula, P. L., Zak, Y., Dua, M., Wapnir, I. L. 2023

  View details for DOI 10.1245/s10434-022-13050-6

  View details for PubMedID 36602659

• A Novel Fat-Augmented Omentum-Based Construct for Unilateral and Bilateral Free-Flap Breast Reconstruction in Underweight and Normal Weight Women Receiving Nipple or Skin-Sparing Mastectomies. Annals of surgical oncology Nguyen, D. H., Rochlin, D. H., Deptula, P. L., Zak, Y., Dua, M., Wapnir, I. L. 2022

  Abstract

  BACKGROUND: Autologous tissue has proven advantages, however it is often not an option for women of low or normal body mass index (BMI). Omentum has been used sparingly, typically as a pedicled flap to correct breast deformities, but is considered suboptimal for full breast reconstruction. We developed a new construct, the omental fat-augmented free flap (O-FAFF) as an alternative for breast reconstruction.METHODS: O-FAFF involves laparoscopic omentum harvesting, creation of an acellular dermal matrix shell for its encasement, and lipoinjection to augment volume. The gastroepiploic vessels are microsurgically anastomosed to internal mammary vessels. Tissue and O-FAFF construct weights as well as outcomes are reported.RESULTS: Thirty-four consecutive women (50 breasts) received O-FAFF breast reconstruction after 18 unilateral and 16 bilateral mastectomies (10 non-nipple-sparing, 40 nipple-sparing). Thirty-seven were immediate and 13 were revisions of previous breast reconstructions. Patient mean age was 48.2 (range 23-73) years and mean BMI was 22.3 (range 17.6-32.4) kg/m2. Mean follow-up was 14.8 (range 3-33) months. The median weight of the omentum was 161.7g (range 81-852, interquartile range [IQR] 102) and the mean ratio of fat to omentum weight was 0.73 (range 0.22-1.38) and 1.97 (range 0.24-3.8) for unilateral and bilateral cases, respectively. Postoperative pain scores and oral morphine equivalent consumption were more favorable for the O-FAFF group compared with controls (p<0.001). Follow-up breast MRI demonstrated intact perfusion and no fat necrosis.CONCLUSIONS: The O-FAFF is ideally suited for women of lower BMI and could dramatically increase the number of women who are candidates for autologous breast reconstruction.

  View details for DOI 10.1245/s10434-022-12975-2

  View details for PubMedID 36567386

• Comparison of Spleen-Preservation vs Splenectomy in Minimally Invasive Distal Pancreatectomy: A Propensity-Matched Analysis Timmerhuis, H. C., Ngongoni, R. F., Jensen, C., Baiocchi, M., DeLong, J. C., Dua, M. M., Norton, J. A., Poultsides, G. A., Worth, P. J., Visser, B. C. LIPPINCOTT WILLIAMS & WILKINS. 2022: S52

  View details for Web of Science ID 000867877000130

• Surgical Indications and Outcomes of Resection for Pancreatic Neuroendocrine Tumors with Vascular Involvement. Cancers Li, A. Y., Visser, B. C., Dua, M. M. 2022; 14 (9)

  Abstract

  Complete surgical resection of pancreatic neuroendocrine tumors (pNETs) has been suggested as the only potentially curative treatment. A proportion of these tumors will present late during disease progression, and invade or encase surrounding vasculature; therefore, surgical treatment of locally advanced disease remains controversial. The role of surgery with vascular reconstruction in pNETs is not well defined, and there is considerable variability in the use of aggressive surgery for these tumors. Accurate preoperative assessment is critical to evaluate individual considerations, such as anatomical variants, areas and lengths of vessel involvement, proximal and distal targets, and collateralization secondary to the degree of occlusion. Surgical approaches to address pNETs with venous involvement may include thrombectomy, traditional vein reconstruction, a reconstruction-first approach, or mesocaval shunting. Although the amount of literature on pNETs with vascular reconstruction is limited to case reports and small institutional series, the last two decades of studies have demonstrated that aggressive resection of these tumors can be performed safely and with acceptable long-term survival.

  View details for DOI 10.3390/cancers14092312

  View details for PubMedID 35565442

• Radiographic, Biochemical, or Pathologic Response to Neoadjuvant Chemotherapy in Resected Pancreatic Cancer: Which Is Best? Javadi, C., Chang, J., Forgo, E., Ahmad, M., Fisher, G. A., Chang, D. T., Delitto, D. J., Dua, M. M., Lee, B., Visser, B. C., Norton, J. A., Poultsides, G. A. SPRINGER. 2022: 351

  View details for Web of Science ID 000789811800041

• Minimizing Postoperative Pain in Autologous Breast Reconstruction With the Omental Fat-Augmented Free Flap. Annals of plastic surgery Deptula, P., Zak, Y., Dua, M., Wapnir, I., Nguyen, D. 2022

  Abstract

  INTRODUCTION: The omental fat-augmented free flap (O-FAFF) is a recently developed technique for autologous breast reconstruction. Our aim of the study is to evaluate the outcomes of our early case series. We assess the O-FAFF donor site morbidity in terms of postoperative pain, narcotic, and antiemetic use.METHODS: A retrospective analysis of patients undergoing O-FAFF from 2019 to 2021 was performed. Patients were evaluated for demographic data, operative time, hospital course, and complications. Mean pain scores (1-10 scale) and narcotic pain medication use in oral morphine equivalents and doses of antiemetic medications during their hospital course were analyzed. We compared outcomes of our O-FAFF group with those of a control group of patients who underwent breast reconstruction with traditional free abdominal tissue transfer.RESULTS: A total of 14 patients underwent O-FAFF breast reconstruction, representing 23 breasts. Patients had an average age of 48.5 years (±2.3 years) and body mass index of 22.6 kg/m2 (±1.09 kg/m2). Average follow-up was 232 days (±51 days). Average mastectomy weight was 245.6 g (±30.2 g) and average O-FAFF weight was 271 g (±31.7 g). Average pain scores on postoperative day 1 (POD1), POD2, and POD3 were 3.1 (±0.28), 2.8 (±0.21), and 2.1 (±0.35), respectively. The average narcotic use by patients in oral morphine equivalents on POD1, POD2, and POD3 are 24.3 (±5.5), 21.9 (±4.6), and 6.2 (±2.4), respectively. Total narcotic use during hospital stay was 79.4 mg (±11.1 mg). Average pain scores and narcotic use are significantly lower when compared with a previously published cohort of patients who underwent autologous breast reconstruction with free abdominal tissue transfer (P < 0.05). Average antiemetic use was lower in the O-FAFF group compared with the control group: 3.5 versus 4.8 doses (P = 0.6). Hospital length of stay was 3.0 days (±0.0 days). No complications were noted (0%). Patients were universally satisfied with their reconstructive outcome (100%).CONCLUSIONS: The O-FAFF is proven to be a viable method of autologous breast reconstruction. Early series of patients undergoing O-FAFF reconstruction suggest a lower donor site morbidity as demonstrated by lower postoperative pain scores and lower consumptions of narcotic pain medications.

  View details for DOI 10.1097/SAP.0000000000003084

  View details for PubMedID 35180753

• Creating a Biological Breast Implant with an Omental Fat-Augmented Free Flap. Plastic and reconstructive surgery Nguyen, D. H., Ma, I. T., Choi, Y. K., Zak, Y., Dua, M. M., Wapnir, I. L. 1800

  Abstract

  SUMMARY: Women with inadequate myocutaneous or fasciocutaneous soft-tissue donor sites for breast reconstruction after mastectomy are mostly limited to implants. Alternative substitutes are needed for those who do not want-or in whom there are contraindications for-implant-based reconstruction. The authors report a novel technique using an omental fat-augmented free flap to create an autologous breast mound that has comparable shape and projection to a breast implant. Three patients with breast cancer who desired unilateral reconstruction were identified in the period 2019 to 2020. All had insufficient traditional autologous sites and were averse to the use of implants. A nipple-sparing mastectomy was performed, and the omentum was laparoscopically harvested and fat-grafted ex vivo and then encased in acellular dermal matrix for microvascular anastomoses. The body mass indexes of the three patients were 17.6, 25, and 28.3 kg/m2. Each individual's mastectomy specimens and corresponding omentum plus fat-grafting weights were 113.7/228, 271/293, and 270/360 g. No postoperative complications occurred. The reconstructed breast remains soft, with stable breast volume at 6 months and without evidence of fat necrosis. This novel use of fat grafting into an omental flap enveloped in acellular dermal matrix, the omental fat-augmented free flap, provides a viable and successful autologous alternative for patients who are not candidates for traditional autologous breast reconstruction options because of body habitus or personal preference.

  View details for DOI 10.1097/PRS.0000000000008963

  View details for PubMedID 35103642

• Novel Technique of Breast Reconstruction with Omental Fat-Augmented Free Flap Improves Donor Site Morbidity and Reduces Postoperative Narcotic Use Deptula, P. L., Zak, Y., Dua, M. M., Wapnir, I. L., Nguyen, D. ELSEVIER SCIENCE INC. 2021: S36-S37

  View details for Web of Science ID 000718303100045

• More Than an ERAS Pathway is Needed to Meet Target Length of Stay After Pancreaticoduodenectomy. The Journal of surgical research Ayala, C. I., Li, A. Y., Lu, A., Wilson, A., Bergquist, J. R., Poultsides, G. A., Norton, J. A., Visser, B. C., Dua, M. M. 2021; 270: 195-202

  Abstract

  BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols have been successfully instituted for pancreaticoduodenectomy (PD). This study evaluates reasons patients fail to meet length of stay (LOS) and areas for pathway improvement.MATERIALS AND METHODS: A multidisciplinary team developed and implemented an ERAS protocol for open PD in 2017. The study includes a medical record review of all patients who were perioperatively managed with the ERAS protocol and failed to meet LOS after PD procedures. Target LOS was defined as 7 d.RESULTS: From 2017 to 2020, 44% (93 of 213) of patients using ERAS protocol after PD procedures failed to meet target LOS. The most common reason to fail target LOS was ileus or delayed gastric emptying (47 of 93, LOS 11). Additional reasons included work-up of leukocytosis or pancreatic leak (17 of 93, LOS 14), additional "night" of observation (14 of 93, LOS 8), and orthostatic hypotension (3 of 93, LOS 10). Of these additional 46 patients, 19 patients underwent computed tomography (on or after POD 7) and only four patients received additional inpatient intervention.CONCLUSIONS: The most common reason for PD pathway failure included slow return of gastrointestinal function, a known complication after PD. The remaining patients were often kept for observation without additional intervention. This group represents an actionable cohort to target for improving LOS through surgeon awareness rather than protocol modification.

  View details for DOI 10.1016/j.jss.2021.08.034

  View details for PubMedID 34688991

• Regional lymph node sampling in hepatoma resection: insight into prognosis. HPB : the official journal of the International Hepato Pancreato Biliary Association Bergquist, J. R., Li, A. Y., Javadi, C. S., Lee, B., Norton, J. A., Poultsides, G. A., Dua, M. M., Visser, B. C. 2021

  Abstract

  BACKGROUND: The importance of regional lymph node sampling (LNS) during resection of hepatocellular carcinoma (HCC) is poorly understood. This study sought to ameliorate this knowledge gap through a nationwide population-based analysis.METHODS: Patients who underwent liver resection (LR) for HCC were identified from Surveillance, Epidemiology and End Results (SEER-18) database (2003-2015). Cohort-based clinicopathologic comparisons were made based on completion of regional LNS. Propensity-score matching reduced bias. Overall and disease-specific survival (OS/DSS) were analyzed.RESULTS: Among 5395 patients, 835 (15.4%) underwent regional LNS. Patients undergoing LNS had larger tumors (7.0vs4.8cm) and higher T-stage (30.9 vs. 17.6% T3+, both p<0.001). Node-positive rate was 12.0%. Median OS (50 months for both) and DSS (28 vs. 29 months) were similar between cohorts, but node-positive patients had decreased OS/DSS (20/16 months, p<0.01). Matched patients undergoing LNS had equivalent OS (46 vs. 43 months, p=0.869) and DSS (27 vs. 29 months, p=0.306) to non-LNS patients. The prognostic impact of node positivity persisted after matching (OS/DSS 24/19 months, p<0.01). Overall disease-specific mortality were both independently elevated (overall HR 1.71-unmatched, 1.56-matched, p<0.01; disease-specific HR 1.40-unmatched, p<0.01, 1.25-matched, p=0.09).CONCLUSION: Regional LNS is seldom performed during resection for HCC, but it provides useful prognostic information. As the era of adjuvant therapy for HCC begins, surgeons should increasingly consider performing regional LNS to facilitate optimal multidisciplinary management.

  View details for DOI 10.1016/j.hpb.2021.01.006

  View details for PubMedID 33563547

• Surgical resection of leiomyosarcoma of the inferior vena cava: A case series and literature review. Surgical oncology Zhou, M., Javadi, C., Charville, G. W., Bui, N. Q., Harris, E. J., Poultsides, G. A., Norton, J. A., Visser, B., Lee, B., Dua, M. M., Ganjoo, K. N. 2021; 39: 101670

  Abstract

  We review our institution's experience in treating leiomyosarcomas involving the inferior vena cava, and we offer guidance on the management.A text-based search was performed to identify all patients who underwent surgical resection between January 2002 and October 2020. Clinicopathologic data, intraoperative variables, and outcomes were extracted from chart review.Twelve of 16 patients (75%) had localized disease; the remaining had limited metastatic disease. Seven of 16 patients (44%) received neoadjuvant chemotherapy or radiation; three patients had partial responses, and four patients had stable disease using RECIST 1.1 criteria. IVC reconstruction was performed in 14 of 16 patients (88%); IVC was ligated for the remaining two patients. Half of all patients had R0 resection on final pathology; the remaining had R1 resections. Progression-free survival (PFS) and overall survival (OS) were not statistically different between patients with R0 and R1 resection. Median PFS was 1.8 years (95% CI 0.89 - not reached); median OS was 6.5 years (1.8 - not reached). Only one patient (6%) experienced local disease recurrence; 4 of 16 patients (25%) experienced disease recurrence distally without local recurrence.Resection of IVC leiomyosarcomas at a sarcoma referral center with experience in vascular reconstruction can lead to many years of recurrence-free survival. Surgical resection should be offered to patients with a low volume of metastatic disease to reduce local complications from the primary tumor, many of which exert significant mass effect on surrounding organs. For patients with metastatic disease or large, high-risk tumors, neoadjuvant chemotherapy can provide a biologic test of disease stability prior to resection.

  View details for DOI 10.1016/j.suronc.2021.101670

  View details for PubMedID 34710646

• Neoadjuvant Capecitabine/Temozolomide for Locally Advanced or Metastatic Pancreatic Neuroendocrine Tumors. Pancreas Squires, M. H., Worth, P. J., Konda, B., Shah, M. H., Dillhoff, M. E., Abdel-Misih, S., Norton, J. A., Visser, B. C., Dua, M., Pawlik, T. M., Schmidt, C. R., Poultsides, G., Cloyd, J. M. 2020

  Abstract

  OBJECTIVES: The combination chemotherapy regimen capecitabine/temozolomide (CAPTEM) is efficacious for metastatic well-differentiated pancreatic neuroendocrine tumors (PNETs), but its role in the neoadjuvant setting has not been established.METHODS: The outcomes of all patients with locally advanced or resectable metastatic PNETs who were treated with neoadjuvant CAPTEM between 2009 and 2017 at 2 high-volume institutions were retrospectively reviewed.RESULTS: Thirty patients with locally advanced PNET (n = 10) or pancreatic neuroendocrine hepatic metastases (n = 20) received neoadjuvant CAPTEM. Thirteen patients (43%) exhibited partial radiographic response (PR), 16 (54%) had stable disease, and 1 (3%) developed progressive disease. Twenty-six (87%) patients underwent resection (pancreatectomy [n = 12], combined pancreatectomy and liver resection [n = 8], or major hepatectomy alone [n = 6]); 3 (18%) declined surgery despite radiographic PR, and 1 (3%) underwent aborted pancreatoduodenectomy. Median primary tumor size was 5.5 cm, and median Ki-67 index was 3.5%. Rates of PR were similar across tumor grades (P = 0.24). At median follow-up of 49 months, median progression-free survival was 28.2 months and 5-year overall survival was 63%.CONCLUSIONS: Neoadjuvant CAPTEM is associated with favorable radiographic objective response rates for locally advanced or metastatic PNET and may facilitate selection of patients appropriate for surgical resection.

  View details for DOI 10.1097/MPA.0000000000001500

  View details for PubMedID 32132509

• Pancreatic grade 3 neuroendocrine tumors behave similarly to neuroendocrine carcinomas following resection: a multi-center, international appraisal of the WHO 2010 and WHO 2017 staging schema for pancreatic neuroendocrine lesions. HPB : the official journal of the International Hepato Pancreato Biliary Association Worth, P. J., Leal, J., Ding, Q., Trickey, A., Dua, M. M., Chatzizacharias, N., Soonawalla, Z., Athanasopoulos, P., Toumpanakis, C., Hansen, P., Parks, R. W., Connor, S., Parker, K., Koea, J., Srinavasa, S., Ielpo, B., Vicente Lopez, E., Lawrence, B., Visser, B. C., International Pancreatic Neuroendocrine Tumor Study Group 2020

  Abstract

  BACKGROUND: In 2017, the WHO updated their 2010 classification of pancreatic neuroendocrine tumors, introducing a well-differentiated, highly proliferative grade 3 tumor, distinct from neuroendocrine carcinomas. The aim of this study was to investigate the clinical significance of this update in a large cohort of resected tumors.METHODS: Using a multicenter, international dataset of patients with pancreatic neuroendocrine lesions, patients were classified both according to the WHO 2010 and 2017 schema. Multivariable survival analyses were performed, and the models were evaluated for discrimination ability and goodness of fit.RESULTS: Excluding patients with a known germline MEN1 mutation and incomplete data, 544 patients were analyzed. The performance of the WHO 2010 and 2017 models was similar, however surgically resected grade 3 tumors behaved very similarly to neuroendocrine carcinomas.CONCLUSION: The addition of a grade 3 NET classification may be of limited utility in surgically resected patients, as these lesions have similar postoperative survival compared to carcinomas. While the addition may allow for a more granular evaluation of novel treatment strategies, surgical intervention for high grade tumors should be considered judiciously.

  View details for DOI 10.1016/j.hpb.2019.12.014

  View details for PubMedID 32081540

• Laparoscopic hepatic lobectomy for symptomatic polycystic liver disease. HPB : the official journal of the International Hepato Pancreato Biliary Association Li, A. Y., Bergquist, J. R., August, A. T., Dua, M. M., Poultsides, G. A., Visser, B. C. 2020

  Abstract

  Laparoscopic fenestration has largely replaced open fenestration of liver cysts. However, most hepatectomies for polycystic liver disease (PCLD) are performed open. Outcomes data on laparoscopic hepatectomy for PCLD are lacking.Patients who underwent surgery for PCLD at a single institution between 2010 and 2019 were reviewed and grouped by operative approach. Pre- and post-operative volumes were calculated for patients who underwent resection. Primary outcomes were: volume reduction, re-admission and postoperative complications.Twenty-six patients were treated for PCLD: 13 laparoscopic fenestration, nine laparoscopic hepatectomy, three open hepatectomy and one liver transplantation. Median length of stay for patients after laparoscopic resection was 3 days (IQR 2-3). The only complication was post-operative atrial fibrillation in one patient. There were no readmissions. Overall volume reduction was 51% (range 22-69) for all resections, 32% (range 22-46) after open resection and 56% (range 39-69) after laparoscopic resection.Volume reduction achieved through laparoscopic approach exceeded open volume reduction at this institution and is comparable to volume reduction in previously published open resection series. Adequate volume reduction can be accomplished by laparoscopic means with acceptable postoperative morbidity.

  View details for DOI 10.1016/j.hpb.2020.04.010

  View details for PubMedID 32451237

• Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis A Single-stage Procedure for Walled-off Pancreatic Necrosis ANNALS OF SURGERY Driedger, M., Zyromski, N. J., Visser, B. C., Jester, A., Sutherland, F. R., Nakeeb, A., Dixon, E., Dua, M. M., House, M. G., Worhunsky, D. J., Munene, G., Ball, C. G. 2020; 271 (1): 163–68

  View details for DOI 10.1097/SLA.0000000000003048

  View details for Web of Science ID 000525016300029

• Nearing the Summit: Associating Liver Partitioning and Portal Ligation for Staged Hepatectomy (ALPPS) in Progressive Carcinoid Disease. Digestive diseases and sciences Bergquist, J. R., Li, A. Y., Chang, E. M., Scott, G. D., Dua, M. M., Visser, B. C. 2020

  View details for DOI 10.1007/s10620-020-06257-8

  View details for PubMedID 32307614

• Evaluation of Outcomes Following Surgery for Locally Advanced Pancreatic Neuroendocrine Tumors. JAMA network open Titan, A. L., Norton, J. A., Fisher, A. T., Foster, D. S., Harris, E. J., Worhunsky, D. J., Worth, P. J., Dua, M. M., Visser, B. C., Poultsides, G. A., Longaker, M. T., Jensen, R. T. 2020; 3 (11): e2024318

  Abstract

  Although outcome of surgical resection of liver metastases from pancreatic neuroendocrine tumors (PNETs) has been extensively studied, little is known about surgery for locally advanced PNETs; it was listed recently by the European neuroendocrine tumor society as a major unmet need.To evaluate the outcome of patients who underwent surgery for locally aggressive PNETs.This retrospective single-center case series reviewed consecutive patients who underwent resection of T3/T4 PNETs at a single academic institution. Data collection occurred from 2003 to 2018. Data analysis was performed in August 2019.Disease-free survival (primary outcome) and overall mortality (secondary outcome) were assessed with Kaplan-Meier analysis. Recurrence risk (secondary outcome, defined as identification of tumor recurrence on imaging) was assessed with Cox proportional hazard models adjusting for covariates.In this case series, 99 patients with locally advanced nondistant metastatic PNET (56 men [57%]) with a mean (SEM) age of 57.0 (1.4) years and a mean (SEM) follow-up of 5.3 (0.1) years underwent surgically aggressive resections. Of those, 4 patients (4%) underwent preoperative neoadjuvant treatment (including peptide receptor radionuclide therapy and chemotherapy); 18 patients (18%) underwent pancreaticoduodenectomy, 68 patients (69%) had distal or subtotal pancreatic resection, 10 patients (10%) had total resection, and 3 patients (3%) had other pancreatic procedures. Additional organ resection was required in 86 patients (87%): spleen (71 patients [71%]), major blood vessel (17 patients [17%]), bowel (2 patients [2%]), stomach (4 patients [4%]), and kidney (2 patients [2%]). Five-year disease-free survival was 61% (61 patients) and 5-year overall survival was 91% (91 patients). Of those living, 75 patients (76%) had an Eastern Cooperative Oncology Group score of less than or equal to 1 at last followup. Lymph node involvement (HR, 7.66; 95% CI, 2.78-21.12; P < .001), additional organ resected (HR, 6.15; 95% CI, 1.61-23.55; P = .008), and male sex (HR, 3.77; 95% CI, 1.68-8.97; P = .003) were associated with increased risk of recurrence. Functional tumors had a lower risk of recurrence (HR, 0.23; CI, 0.06-0.89; P = .03). Required resection of blood vessels was not associated with a significant increase recurrence risk.In this case series, positive lymph node involvement and resection of organs with tumor involvement were associated with an increased recurrence risk. These subgroups may require adjuvant systemic treatment. These findings suggest that patients with locally advanced PNETs who undergo surgical resection have excellent disease-free and overall survival.

  View details for DOI 10.1001/jamanetworkopen.2020.24318

  View details for PubMedID 33146734

• Postoperative Outcomes of Laparoscopic vs Robotic Distal Pancreatectomy: A Propensity-Matched Analysis Jensen, C. W., Baiocchi, M., Dua, M. M., Poultsides, G. A., Norton, J. A., Worth, P. J., Visser, B. C. ELSEVIER SCIENCE INC. 2019: S181–S182

  View details for Web of Science ID 000492740900344

• Management of Ileal Neuroendocrine Tumors with Liver Metastases. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Fisher, A. T., Titan, A. L., Foster, D. S., Worth, P. J., Poultsides, G. A., Visser, B. C., Dua, M. M., Norton, J. A. 2019

  Abstract

  Assessment of treating metastatic ileal neuroendocrine tumors (NETs) with complete resection of primary tumor, nodal and liver metastases, plus administration of long-acting somatostatin analogues (SSAs).A prospective database was queried for patients with ileal or pancreatic NETs with pathology-confirmed liver metastases and tumor somatostatin receptors. Patients did not have MEN-1 and had no previous treatment. The impacts of SSA treatment on the primary outcome of survival and secondary outcome of progression-free survival were assessed with Kaplan-Meier analysis. Log rank test was used to compare overall and progression-free survival among groups.Seventeen ileal NET patients and 36 pancreatic NET patients who underwent surgical resection between 2001 and 2018, who had pathology-confirmed liver metastases and confirmed tumor somatostatin receptors, did not have MEN-1, and had no previous treatment were identified. Median follow-up for patients with ileal NETs was 80 months (range 0-197 months) and 32 months (range 1-182 months) for pancreatic NETs. Five-year survival was 93% and 72% for ileal and pancreatic NET, respectively. Progression-free 5-year survival was 70% and 36% for ileal and pancreatic NET, respectively. Overall 5-year survival for pNETs was greater in those patients treated with SSA (79%) compared to those who underwent surgery alone (34%, p < 0.01). The average ECOG score was low for surviving patients with ileal (0.15) and pancreatic NET (0.73) indicating a good quality of life.Resection of primary lymph node and liver metastatic ileal or pancreatic NETs followed with continued SSAs is associated with an excellent progression-free and overall survival and minimal side effects.

  View details for DOI 10.1007/s11605-019-04309-7

  View details for PubMedID 31346887

• Isolated pancreatic tail remnants after transgastric necrosectomy can be observed. The Journal of surgical research Dua, M. M., Jensen, C. W., Friedland, S., Worth, P. J., Poultsides, G. A., Norton, J. A., Park, W. G., Visser, B. C. 2018; 231: 109–15

  Abstract

  BACKGROUND: Severe necrotizing pancreatitis may result in midbody necrosis and ductal disruption leaving an isolated pancreatic tail. The purpose of this study was to characterize outcomes among patients with an isolated tail remnant who underwent transgastric drainage or necrosectomy (endoscopic or surgical) and determine the need for subsequent operative management.MATERIALS AND METHODS: Patients with necrotizing pancreatitis and retrogastric walled-off collections treated by surgical transgastric necrosectomy or endoscopic cystgastrostomy± necrosectomy between 2009 and 2017 were identified by a retrospective chart review. All available preprocedure and postprocedure imaging was reviewed for evidence of isolated distal pancreatic tail remnants.RESULTS: Seventy-four patients were included (40 surgical and 34 endoscopic). All the patients in the surgical group underwent laparoscopic transgastric necrosectomy; the endoscopic group consisted of 26 patients for pseudocyst drainage and eight patients for necrosectomy. A disconnected pancreatic tail was identified in 22 (29%) patients (13 laparoscopic and nine endoscopic). After the creation of the "cystgastrostomy," there were no external fistulas despite the viable tail. Of the 22 patients, four patients developed symptoms at a median of 23months (two, recurrent episodic pancreatitis; two, intractable pain). Two patients (both initially in endoscopic group) ultimately required distal pancreatectomy and splenectomy at 24 and 6months after index procedure.CONCLUSIONS: Patients with a walled-off retrogastric collection and an isolated viable tail are effectively managed by a transgastric approach. Despite this seemingly "unstable anatomy," the creation of an internal fistula via surgical or endoscopic "cystgastrostomy" avoids external fistulas/drains and the short-term necessity of surgical distal pancreatectomy. A very small subset requires intervention for late symptoms.

  View details for PubMedID 30278917

• Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis: A Single-stage Procedure for Walled-off Pancreatic Necrosis. Annals of surgery Driedger, M., Zyromski, N. J., Visser, B. C., Jester, A., Sutherland, F. R., Nakeeb, A., Dixon, E., Dua, M. M., House, M. G., Worhunsky, D. J., Munene, G., Ball, C. G. 2018

  Abstract

  OBJECTIVE: The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients.BACKGROUND: WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention.METHODS: A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention <30 days were excluded. Differences across centers were evaluated using a P value of <0.05 as significant.RESULTS: One hundred seventy-eight total patients were analyzed (mean WON diameter = 14 cm, 64% male, mean age = 51 years) across 3 centers. The majority required inpatient admission with a median preoperative length of hospital stay of 29 days (25% required preoperative critical care support). Most (96%) patients underwent a TGN. The median duration of time between the onset of pancreatitis symptoms and operative intervention was 60 days. Thirty-nine percent of the necrosum was infected. Postoperative morbidity and mortality were 38% and 2%, respectively. The median postoperative length of hospital length of stay was 8 days, with the majority of patients discharged home. The median length of follow-up was 21 months, with 91% of patients having complete clinical resolution of symptoms at a median of 6 weeks. Readmission to hospital and/or a repeat intervention was also not infrequent (20%).CONCLUSION: Surgical TGN is an excellent 1-stage surgical option for symptomatic WON in a highly selected group of patients. Precise surgical technique and long-term outpatient follow-up are mandatory for optimal patient outcomes.

  View details for PubMedID 30216220

• Monitoring Gastric Myoelectric Activity After Pancreaticoduodenectomy for Diet "Readiness". American journal of physiology. Gastrointestinal and liver physiology Dua, M. M., Navalgund, A., Axelrod, S., Axelrod, L., Worth, P. J., Norton, J. A., Poultsides, G. A., Triadafilopoulos, G., Visser, B. C. 2018

  Abstract

  INTRODUCTION: Post-operative delayed gastric emptying (DGE) is a frustrating complication of pancreaticoduodenectomy (PD). We studied whether monitoring of post-operative gastric motor activity using a novel wireless patch system can identify patients at risk for DGE.METHODS: Eighty-one patients were prospectively studied since 2016; 75 patients were analyzed for this study. After PD, battery-operated wireless patches (G-Tech Medical) that acquire gastrointestinal myoelectrical signals are placed on the abdomen and transmit data by Bluetooth. Patients were divided into EARLY and LATE groups, by diet tolerance of 7 days (ERAS goal). Subgroup analysis was done of patients included after ERAS initiation.RESULTS: The EARLY and LATE groups had 50 and 25 patients, respectively, with length of stay (LOS) 7 and 11 days (p<0.05). Nasogastric insertion was required in 44% of the LATE group. Tolerance of food was noted by 6 vs 9 days in the EARLY vs LATE group (p<0.05) with higher cumulative gastric myoelectrical activity. Diminished gastric myoelectrical activity accurately identified delayed tolerance to regular diet in a logistical regression analysis (area under the curve (AUC), 0.81; 95% CI, 0.74-0.92). The gastric myoelectrical activity also identified delayed LOS status with an AUC of 0.75 (95% CI, 0.67-0.88). Stomach signal continued to be predictive in 90% of the ERAS cohort despite earlier oral intake.CONCLUSIONS: Measurement of gastric activity after PD can distinguish patients with shorter or longer times to diet. This non-invasive technology provides data to identify patients at risk for DGE and may guide timing of oral intake by gastric "readiness."

  View details for PubMedID 30048596

• Transgastric pancreatic necrosectomy-expedited return to prepancreatitis health JOURNAL OF SURGICAL RESEARCH Dua, M. M., Worhunsky, D. J., Malhotra, L., Park, W. G., Poultsides, G. A., Norton, J. A., Visser, B. C. 2017; 219: 11–17

  Abstract

  The best operative strategy for necrotizing pancreatitis remains controversial. Traditional surgical necrosectomy is associated with significant morbidity; endoscopic and percutaneous strategies require repeated interventions with prolonged hospitalizations. We have developed a transgastric approach to pancreatic necrosectomy to overcome the shortcomings of the other techniques described.Patients with necrotizing pancreatitis treated from 2009 to 2016 at an academic center were retrospectively reviewed. Open or laparoscopic transgastric necrosectomy was performed if the area of necrosis was walled-off and in a retrogastric position on cross-sectional imaging. Study endpoints included postoperative complications and mortality.Forty-six patients underwent transgastric necrosectomy (nine open and 37 laparoscopic). Median (interquartile range) preoperative Acute Physiologic and Chronic Health Evaluation II score was 6 (3-12). Seventy percent of patients had >30% necrosis on preoperative imaging; infected necrosis was present in 35%. Median total length of stay (LOS) was 6 (3-12) d. No patient required a second operative debridement; four patients (9%) had short-term postoperative percutaneous drainage for residual fluid collections. Median follow-up was 1 y; there were no fistula or wound complications. Six patients (13%) had postoperative bleeding; five patients received treatment by image-guided embolization. There was one death in the cohort.Transgastric pancreatic necrosectomy allows for effective debridement with a single definitive operation. When anatomically suitable, this operative strategy offers expedited recovery and avoids long-term morbidity associated with fistulas and prolonged drainage.

  View details for PubMedID 29078869

• Management of Postoperative Pancreatic Fistula: Drain Position Matters Malhotra, L., Dua, M. M., Leal, J. N., Poultsides, G. A., Norton, J. A., Visser, B. C. ELSEVIER SCIENCE INC. 2017: E123–E124

  View details for DOI 10.1016/j.jamcollsurg.2017.07.858

  View details for Web of Science ID 000413319300298

• Surgical Approaches to Chronic Pancreatitis: Indications and Techniques. Digestive diseases and sciences Dua, M. M., Visser, B. C. 2017

  Abstract

  There are a number of surgical strategies for the treatment of chronic pancreatitis. The optimal intervention should provide effective pain relief, improve/maintain quality of life, preserve exocrine and endocrine function, and manage local complications. Pancreaticoduodenectomy was once the standard operation for patients with chronic pancreatitis; however, other procedures such as the duodenum-preserving pancreatic head resections and its variants have been introduced with good long-term results. Pancreatic duct drainage via a lateral pancreaticojejunostomy continues to be effective in ameliorating symptoms and expediting return to normal lifestyle in many patients. This review summarizes operative indications and gives an overview of the different surgical strategies in treating chronic pancreatitis.

  View details for DOI 10.1007/s10620-017-4526-x

  View details for PubMedID 28281166

• Fukuoka and AGA Criteria Have Superior Diagnostic Accuracy for Advanced Cystic Neoplasms than Sendai Criteria. Digestive diseases and sciences Sighinolfi, M., Quan, S. Y., Lee, Y., Ibaseta, A., Pham, K., Dua, M. M., Poultsides, G. A., Visser, B. C., Norton, J. A., Park, W. G. 2017; 62 (3): 626-632

  Abstract

  The aim of this study was to compare the American Gastroenterological Association guidelines (AGA criteria), the 2012 (Fukuoka criteria), and 2006 (Sendai criteria) International Consensus Guidelines for the diagnosis of advanced pancreatic cystic neoplasms.All patients who underwent surgical resection of a pancreatic cyst from August 2007 through January 2016 were retrospectively analyzed at a single tertiary academic center. Relevant clinical and imaging variables along with pathology results were collected to determine appropriate classification for each guideline. Advanced pancreatic cystic neoplasms were defined by the presence of either high-grade dysplasia or cystic adenocarcinoma. Diagnostic accuracy was measured by ROC analysis.A total of 209 patients were included. Both the AGA and Fukuoka criteria had a higher diagnostic accuracy for advanced neoplastic cysts than the Sendai criteria: AGA ROC 0.76 (95% CI 0.69-0.81), Fukuoka ROC 0.78 (95% CI 0.74-0.82), and Sendai ROC 0.65 (95% CI 0.61-0.69) (p < 0.0001). There was no difference between the Fukuoka and the AGA criteria. While the sensitivity was higher in the Fukuoka criteria compared to the AGA criteria (97.7 vs. 88.6%), the specificity was higher in the AGA criteria compared to the Fukuoka criteria (62.4 vs. 58.2%).In a surgical series of patients with pancreatic cysts, the AGA and Fukuoka criteria had superior diagnostic accuracy for advanced neoplastic cysts compared to the original Sendai criteria.

  View details for DOI 10.1007/s10620-017-4460-y

  View details for PubMedID 28116593

• Recurrent Pyogenic Cholangitis: Got Stones? Digestive diseases and sciences Gholami, S., Wood, L., Berry, G., Triadafilopoulos, G., Visser, B. C., Dua, M. M. 2016; 61 (11): 3147-3150

  View details for PubMedID 26602913

• Laparoscopic hepatectomy in cirrhotics: safe if you adjust technique. Surgical endoscopy Worhunsky, D. J., Dua, M. M., Tran, T. B., Siu, B., Poultsides, G. A., Norton, J. A., Visser, B. C. 2016; 30 (10): 4307-4314

  Abstract

  Minimally invasive liver surgery is a growing field, and a small number of recent reports have suggested that laparoscopic liver resection (LLR) is feasible even in patients with cirrhosis. However, parenchymal transection of the cirrhotic liver is challenging due to fibrosis and portal hypertension. There is a paucity of data regarding the technical modifications necessary to safely transect the diseased parenchyma.Patients undergoing LLR by a single surgeon between 2008 and 2015 were reviewed. Patients with cirrhosis were compared to those without cirrhosis to examine differences in surgical technique, intraoperative characteristics, and outcomes (including liver-related morbidity and general postoperative complication rates).A total of 167 patients underwent LLR during the study period. Forty-eight (29 %) had cirrhosis, of which 43 (90 %) had hepatitis C. Most had Child-Pugh class A disease (85 %). Compared to noncirrhotics, patients with cirrhosis were older, had more comorbidities, and were more likely to have hepatocellular carcinoma. Precoagulation before parenchymal transection was used more frequently in cirrhotics (65 vs. 15 %, P < 0.001), and mean portal triad clamping time was longer (32 vs. 22 min, P = 0.002). There were few conversions to open surgery, though hand-assisted laparoscopy was used as an alternative to converting to open in three patients with cirrhosis. Blood loss was relatively low for both groups. Although there were more postoperative complications among cirrhotics (38 vs. 13 %, P = 0.001), this was almost entirely due to a higher rate of minor (Clavien-Dindo I or II) complications. Liver-related morbidity, major complications, and mortality rates were similar.LLR is safe for selected patients with cirrhosis. The added complexity associated with the division of diseased liver parenchyma may be overcome with some form of technique modification, including more liberal use of precoagulation, portal triad clamping, or a hand-assist port.

  View details for DOI 10.1007/s00464-016-4748-6

  View details for PubMedID 26895906

• Neuroendocrine tumors of the pancreas: Degree of cystic component predicts prognosis. Surgery Cloyd, J. M., Kopecky, K. E., Norton, J. A., Kunz, P. L., Fisher, G. A., Visser, B. C., Dua, M. M., Park, W. G., Poultsides, G. A. 2016; 160 (3): 708-713

  Abstract

  Although most pancreatic neuroendocrine tumors are solid, approximately 10% are cystic. Some studies have suggested that cystic pancreatic neuroendocrine tumors are associated with a more favorable prognosis.A retrospective review of all patients with pancreatic neuroendocrine tumors who underwent operative resection between 1999 and 2014 at a single academic medical center was performed. Based on cross-sectional imaging performed before operation, pancreatic neuroendocrine tumors were classified according to the size of the cystic component relative to the total tumor size: purely cystic (100%), mostly cystic (≥50%), mostly solid (<50%), and purely solid (0%). Clinicopathologic characteristics and recurrence-free survival were assessed between groups.In the study, 214 patients met inclusion criteria: 8 with purely cystic tumors, 7 with mostly cystic tumors, 15 with mostly solid tumors, and 184 with purely solid tumors. The groups differed in terms of tumor size (1.5 ± 0.5, 3.0 ± 1.7, 3.7 ± 2.6, and 4.0 ± 3.5 cm), lymph node positivity (0%, 0%, 26.7%, and 34.2%), intermediate or high grade (0%, 16.7%, 20.0%, and 31.0%), synchronous liver metastases (0%, 14.3%, 20.0%, and 26.6%) and need for pancreaticoduodenectomy (0%, 0%, 6.7%, and 25.0%), respectively. No cases of purely cystic pancreatic neuroendocrine tumors were associated with synchronous liver or lymph node metastasis, intermediate/high grade, recurrence, or death due to disease. Among patients presenting without metastatic disease, 10-year recurrence-free survival was 100% in patients with purely and mostly cystic tumors versus 53.0% in patients with purely and mostly solid tumors; however, this difference did not reach statistical significance.Pancreatic neuroendocrine tumors demonstrate a spectrum of biologic behavior with an increasing cystic component being associated with more favorable clinicopathologic features and prognosis. Purely cystic pancreatic neuroendocrine tumors may represent 1 subset that can be safely observed without immediate resection.

  View details for DOI 10.1016/j.surg.2016.04.005

  View details for PubMedID 27216830

• The significance of underlying cardiac comorbidity on major adverse cardiac events after major liver resection. HPB Tran, T. B., Worhunsky, D. J., Spain, D. A., Dua, M. M., Visser, B. C., Norton, J. A., Poultsides, G. A. 2016; 18 (9): 742-747

  Abstract

  The risk of postoperative adverse events in patients with underlying cardiac disease undergoing major hepatectomy remains poorly characterized.The NSQIP database was used to identify patients undergoing hemihepatectomy and trisectionectomy. Patient characteristics and postoperative outcomes were evaluated.From 2005 to 2012, 5227 patients underwent major hepatectomy. Of those, 289 (5.5%) had prior major cardiac disease: 5.6% angina, 3.1% congestive heart failure, 1% myocardial infarction, 54% percutaneous coronary intervention, and 46% cardiac surgery. Thirty-day mortality was higher in patients with cardiac comorbidity (6.9% vs. 3.7%, P = 0.008), including the incidence of postoperative cardiac arrest requiring cardiopulmonary resuscitation (3.8% vs. 1.2%, P = 0.001) and myocardial infarction (1.7% vs. 0.4%, P = 0.011). Multivariate analysis revealed that functional impairment, older age, and malnutrition, but not cardiac comorbidity, were significant predictors of 30-day mortality. However, prior percutaneous coronary intervention was independently associated with postoperative cardiac arrest (OR 2.999, P = 0.008).While cardiac comorbidity is not a predictor of mortality after major hepatectomy, prior percutaneous coronary intervention is independently associated with postoperative cardiac arrest. Careful patient selection and preoperative optimization is fundamental in patients with prior percutaneous coronary intervention being considered for major hepatectomy as restrictive fluid management and low central venous pressure anesthesia may not be tolerated well by all patients.

  View details for DOI 10.1016/j.hpb.2016.06.012

  View details for PubMedID 27593591

• Biliary Cystadenoma: A Suggested "Cystamatic" Approach? DIGESTIVE DISEASES AND SCIENCES Dua, M. M., Gerry, J., Salles, A., Tran, T. B., Triadafilopoulos, G., Visser, B. C. 2016; 61 (7): 1835-1838

  View details for DOI 10.1007/s10620-015-3943-y

  View details for PubMedID 26514678

• An economic analysis of pancreaticoduodenectomy: should costs drive consumer decisions? AMERICAN JOURNAL OF SURGERY Tran, T. B., Dua, M. M., Worhunsky, D. J., Poultsides, G. A., Norton, J. A., Visser, B. C. 2016; 211 (6): 991-?

  Abstract

  Consumer groups campaign for cost transparency believing that patients will select hospitals accordingly. We sought to determine whether the cost of pancreaticoduodenectomy (PD) should be considered in choosing a hospital.Using the Nationwide Inpatient Sample database, we analyzed charges for patients who underwent PD from 2000 to 2010. Outcomes were stratified by hospital volume.A total of 15,599 PDs were performed in 1,186 hospitals. The median cost was $87,444 (interquartile range $16,015 to $144,869). High volume hospitals (HVH) had shorter hospital stay (11 vs 15 days, P < .001) and mortality (3% vs 7.6%, P < .001). PD performed at low volume hospitals had higher charges compared with HVH ($97,923 vs $81,581, P < .001). On multivariate analysis, HVH was associated with a lower risk of mortality, while extremes in hospital costs, cardiac comorbidity, and any complication were significant predictors of mortality.Although PDs performed at HVH are associated with better outcomes and lower hospital charges, costs should not be the primary determinant when selecting a hospital.

  View details for DOI 10.1016/j.amjsurg.2015.10.028

  View details for PubMedID 26902956

• Minimally invasive approaches to resection of benign/low-grade gastric tumors SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Salles, A., Dua, M., Friedland, S., Visser, B. 2016; 30 (6): 2624–25

  Abstract

  Tumors in the stomach have traditionally been treated with either subtotal gastrectomy or total gastrectomy, depending on the location. However, many of these lesions are benign spindle cell tumors or adenomas and could be resected with margins. Here, we explore multiple minimally invasive methods for the resection of these tumors. We highlight a wedge resection, a circumferential resection with transverse closure, a transgastric resection, and an endoscopic/laparoscopic submucosal resection. The wedge resection was performed in a 71-year-old man found to have a mass in the stomach on screening upper endoscopy. The biopsy was not definitive, but on CT scan there was a 4.5-cm submucosal mass consistent with a gastrointestinal stromal tumor. The circumferential resection was performed for an 83-year-old woman who had abdominal discomfort which led to an upper endoscopy. She was found to have a mass in the lesser curve of her stomach. Biopsy revealed this to be a gastrointestinal stromal tumor. Ultimately, it was removed when serial CT scans showed that it was growing. The transgastric approach was used for a 75-year-old man who had upper endoscopy for reflux symptoms and was found to have a mass in the stomach. Biopsy showed that it was a gastrointestinal stromal tumor. Due to patient preference, it was initially observed but was eventually removed when it was found to be growing on serial CT scans. The endoscopic/laparoscopic approach was for a 65-year-old man who had an upper endoscopy performed for work-up of melena and was found to have a 5-cm mass at the gastroesophageal junction. The biopsy showed this to be an adenoma, and he went on to have it removed.We identified representative videos from patients treated with each of the above techniques. Small exophytic lesions can be completely excised with a wedge resection using a stapler to fire across the base of the lesion. By contrast, if the lesion is in an awkward location or is too large to remove in this way, a vessel-sealing device can divide the mass from the stomach circumferentially (intragastric resection). The resultant defect in the gastric wall must be repaired transversely to avoid narrowing the lumen. Endophytic lesions can be treated with transgastric resection. Ports are placed directly into the stomach allowing excision from within the stomach. Finally, submucosal resection is ideal for lesions close to the GE junction. This combined endoscopic and laparoscopic approach allows the tumor to be lifted off the muscle fibers and to be resected without transmural injury to the stomach or esophagus.All four patients tolerated the procedure well and were discharged home by postoperative day 2. There were no complications. One patient, the one who underwent the endoscopic/laparoscopic approach and was preoperatively found to have an adenoma on biopsy, was ultimately found to have an invasive component and later underwent total gastrectomy. The other three patients all had gastrointestinal stromal tumors.Minimally invasive techniques should be considered more frequently for the management of benign gastric tumors. The four methods illustrated here can be used safely and result in faster recovery as well as shorter hospital stays compared to traditional approaches.

  View details for PubMedID 26423418

• The First Decade of Laparoscopic Pancreaticoduodenectomy in the United States: Costs and Outcomes Using the Nationwide Inpatient Sample SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Tran, T. B., Dua, M. M., Worhunsky, D. J., Poultsides, G. A., Norton, J. A., Visser, B. C. 2016; 30 (5): 1778-1783

  Abstract

  Minimally invasive pancreaticoduodenectomy (PD) remains an uncommon procedure, and the safety and efficacy remain uncertain beyond single institution case series. The aim of this study is to compare outcomes and costs between laparoscopic (LPD) and open PD (OPD) using a large population-based database.The Nationwide Inpatient Sample database (a sample of approximately 20 % of all hospital discharges) was analyzed to identify patients who underwent PD from 2000 to 2010. Patient demographics, comorbidities, hospital characteristics, inflation-adjusted total charges, and complications were evaluated using univariate and multivariate logistic regression. Hospitals were categorized as high-volume hospitals (HVH) if more than 20 PD (open and laparoscopic) were performed annually, while those performing fewer than 20 PD were classified as low-volume hospitals.Of the 15,574 PD identified, 681 cases were LPD (4.4 %). Compared to OPD, patients who underwent LPD were slightly older (65 vs. 67 years; p = 0.001) and were more commonly treated at HVH (56.6 vs. 66.1 %; p < 0.001). Higher rates of complications were observed in OPD than LPD (46 vs. 39.4 %; p = 0.001), though mortality rates were comparable (5 vs. 3.8 %, p = 0.27). Inflation-adjusted median hospital charges were similar between OPD and LPD ($87,577 vs. $81,833, p = 0.199). However, hospital stay was slightly longer in the OPD group compared to LPD group (12 vs. 11 days, p < 0.001). Stratifying outcomes by hospital volume, LPD at HVH resulted in shorter hospital stays (9 vs. 13 days, p < 0.001), which translated into significantly lower median hospital charges ($76,572 vs. $106,367, p < 0.001).Contrary to fears regarding the potential for compromised outcomes early in the learning curve, LPD morbidity in its first decade is modestly reduced, while hospital costs are comparable to OPD. In high-volume pancreatic hospitals, LPD is associated with a reduction in length of stay and hospital costs.

  View details for DOI 10.1007/s00464-015-4444-y

  View details for PubMedID 26275542

• Missing the obvious: psychosocial obstacles in Veterans with hepatocellular carcinoma HPB Hwa, K. J., Dua, M. M., Wren, S. M., Visser, B. C. 2015; 17 (12): 1124-1129

  Abstract

  Socioeconomic disparities in patients with hepatocellular carcinoma (HCC) influence medical treatment. In addition to socioeconomic barriers, the Veteran population suffers from significant psychosocial obstacles. This study identifies the social challenges that Veterans face while undergoing treatment for HCC.One hundred Veterans at the Palo Alto VA treated for HCC from 2009 to 2014 (50 consecutive patients who underwent a surgical procedure; 50 treated with intra-arterial therapy) were retrospectively reviewed.Substance abuse history was identified in 96%, and half were unemployed. Most patients survived on a limited income [median $1340, interquartile range (IQR) 900-2125]; 36% on ≤ $1000/month, 37% between $1001-2000/month and 27% with >$2000/month. A history of homelessness was found in 30%, more common in those of the lowest income (57% of ≤$1K/month group, 23% of $1-2K/month group and 9% of >$2K/month group, P < 0.01). Psychiatric illness was present in 64/100 patients; among these the majority received ongoing psychiatric treatment. Transportation was provided to 23% of patients who would otherwise have been unable to attend medical appointments.Psychiatric disease and substance abuse are highly prevalent among Veterans with HCC. Most patients survive on a very meager income. These profound socioeconomic and psychosocial problems must be recognized when providing care for HCC to this population to provide adequate treatment and surveillance.

  View details for DOI 10.1111/hpb.12508

  View details for Web of Science ID 000368291100010

• The neurosurgical origins of image-guided surgery CURRENT PROBLEMS IN SURGERY Barrese, J. C., Henderson, J. M. 2015; 52 (12): 476-520

  View details for DOI 10.1067/j.cpsurg.2015.10.001

  View details for Web of Science ID 000367210800002

• Image-guided surgery. Current problems in surgery Azagury, D. E., Dua, M. M., Barrese, J. C., Henderson, J. M., Buchs, N. C., Ris, F., Cloyd, J. M., Martinie, J. B., Razzaque, S., Nicolau, S., Soler, L., Marescaux, J., Visser, B. C. 2015; 52 (12): 476-520

  View details for DOI 10.1067/j.cpsurg.2015.10.001

  View details for PubMedID 26683419

• Using intraoperative laser angiography to safeguard nipple perfusion in nipple-sparing mastectomies. Gland surgery Dua, M. M., Bertoni, D. M., Nguyen, D., Meyer, S., Gurtner, G. C., Wapnir, I. L. 2015; 4 (6): 497-505

  Abstract

  The superior aesthetic outcomes of nipple-sparing mastectomies (NSM) explain their increased use and rising popularity. Fortunately, cancer recurrences involving the nipple-areolar complex (NAC) have been reassuringly low in the range of 1%. Technical considerations and challenges of this procedure are centered on nipple ischemia and necrosis. Patient selection, reconstructive strategies and incision placement have lowered ischemic complications. In this context, rates of full NAC necrosis are 3% or less. The emergence of noninvasive tissue angiography provides surgeons with a practical tool to assess real-time breast skin and NAC perfusion. Herein, we review our classification system of NAC perfusion patterns defined as V1 (from subjacent breast), V2 (surrounding skin), and V3 (combination of V1 + V2). Additionally, we describe the benefits of a first stage operation to devascularize the NAC as a means of improving blood flow to the NAC in preparation for NSM, helping extend the use of NSM to more women. Intraoperative evaluation of skin perfusion allows surgeons to detect ischemia and modify the operative approach to optimize outcomes.

  View details for DOI 10.3978/j.issn.2227-684X.2015.04.15

  View details for PubMedID 26645004

• Severe acute pancreatitis in the community: confusion reigns JOURNAL OF SURGICAL RESEARCH Dua, M. M., Worhunsky, D. J., Tran, T. B., Rumma, R. T., Poultsides, G. A., Norton, J. A., Park, W. G., Visser, B. C. 2015; 199 (1): 44-50

  Abstract

  The management of acute pancreatitis (AP) has evolved through enhanced understanding of the disease. Despite several evidence-based practice guidelines for AP, our hypothesis is that many hospitals still use historical treatments rather than adhere to the current guidelines, which have demonstrated shorter hospital stays, decreased infectious complications, decreased morbidity, and decreased mortality.Seventy-eight patients transferred to our institution with AP from 2010-2014 were retrospectively studied to compare pretransfer versus posttransfer adherence to current practice guidelines. Primary measures included use of antibiotics (abx), enteral nutrition, drainage of asymptomatic pseudocysts, and interventions for necrosis in the early phase (<4 wk).Pretransfer, abx were given to 51 patients; however, posttransfer, abx were discontinued in 33 patients and started in 6 patients within 24 h of admission (pretransfer versus posttransfer abx, 51 versus 24, P < 0.001). Empiric abx for AP were used in 36 patients pretransfer versus 9 patients posttransfer (P < 0.001). Patients were initially nil per os or on total parenteral nutrition in 89%; this was reduced to 17% within 72 h by starting a diet or enteric feeds (pretransfer versus posttransfer feeding, 9 versus 65 patients, P < 0.001). Fifteen transfer patients had pseudocysts that were believed to "require drainage"; five patients received intervention but >4 wk from initial episode of AP. Pretransfer, five patients had pancreatic debridement in the early phase, which resulted in prolonged postoperative length of stay compared with eight patients requiring debridement, which were delayed (early versus late, 56 versus 16 d, P < 0.05).There is still great confusion in the treatment of AP in community hospitals. Primary principles in the care of these patients are not routinely followed despite established guidelines. Increased dissemination is required to prevent lengthy hospitalizations and long-term morbidity.

  View details for DOI 10.1016/j.jss.2015.04.054

  View details for PubMedID 25972313

• Surgical Strategies for the Management of Necrotizing Pancreatitis JOURNAL OF THE PANCREAS Dua, M. M., Worhunsky, D. J., Tran, T. B., Friedland, S., Park, W. G., Visser, B. C. 2015; 16 (6): 547–58

  View details for Web of Science ID 000385225400004

• Hepato-pancreatectomy: perioperative and long term outcomes of synchronous hepatic and pancreatic resection Tran, T. B., Dua, M. M., Visser, B. C., Norton, J. A., Poultsides, G. A. ELSEVIER SCIENCE INC. 2015: E95

  View details for DOI 10.1016/j.jamcollsurg.2015.08.151

  View details for Web of Science ID 000386899000230

• The Effect of Chronic Kidney Disease on Postoperative Outcomes after Major Hepatectomy: Results from the National Surgical Quality Improvement Program Tran, T. B., Dua, M. M., Spain, D. A., Poultsides, G. A., Norton, J. A., Visser, B. C. ELSEVIER SCIENCE INC. 2015: S94–S95

  View details for DOI 10.1016/j.jamcollsurg.2015.07.217

  View details for Web of Science ID 000361119700188

• Missing the obvious: psychosocial obstacles in Veterans with hepatocellular carcinoma. HPB : the official journal of the International Hepato Pancreato Biliary Association Hwa, K. J., Dua, M. M., Wren, S. M., Visser, B. C. 2015

  Abstract

  Socioeconomic disparities in patients with hepatocellular carcinoma (HCC) influence medical treatment. In addition to socioeconomic barriers, the Veteran population suffers from significant psychosocial obstacles. This study identifies the social challenges that Veterans face while undergoing treatment for HCC.One hundred Veterans at the Palo Alto VA treated for HCC from 2009 to 2014 (50 consecutive patients who underwent a surgical procedure; 50 treated with intra-arterial therapy) were retrospectively reviewed.Substance abuse history was identified in 96%, and half were unemployed. Most patients survived on a limited income [median $1340, interquartile range (IQR) 900-2125]; 36% on ≤ $1000/month, 37% between $1001-2000/month and 27% with >$2000/month. A history of homelessness was found in 30%, more common in those of the lowest income (57% of ≤$1K/month group, 23% of $1-2K/month group and 9% of >$2K/month group, P < 0.01). Psychiatric illness was present in 64/100 patients; among these the majority received ongoing psychiatric treatment. Transportation was provided to 23% of patients who would otherwise have been unable to attend medical appointments.Psychiatric disease and substance abuse are highly prevalent among Veterans with HCC. Most patients survive on a very meager income. These profound socioeconomic and psychosocial problems must be recognized when providing care for HCC to this population to provide adequate treatment and surveillance.

  View details for DOI 10.1111/hpb.12508

  View details for PubMedID 26374349

• Hepato-pancreatectomy: how morbid? Results from the national surgical quality improvement project. HPB Tran, T. B., Dua, M. M., Spain, D. A., Visser, B. C., Norton, J. A., Poultsides, G. A. 2015; 17 (9): 763-769

  Abstract

  Simultaneous resection of both the liver and the pancreas carries significant complexity. The objective of this study was to investigate peri-operative outcomes after a synchronous hepatectomy and pancreatectomy (SHP).The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify patients who underwent SHP. Resections were categorized as '< hemihepatectomy', '≥ hemihepatectomy' (hemihepatectomy and trisectionectomy), 'PD' (pancreaticoduodenectomy and total pancreatectomy) and 'distal' (distal pancreatectomy and enucleation).From 2005 to 2013, 480 patients underwent SHP. Patients were stratified based on the extent of resection: '< hemihepatectomy + distal (n = 224)', '≥ hemihepatectomy + distal' (n = 49), '< hemihepatectomy + PD' (n = 83) and '≥ hemihepatectomy + PD' (n = 24). Although the first three groups had a reasonable and comparable safety profile (morbidity 33-51% and mortality 0-6.6%), the '≥ hemihepatectomy + PD' group was associated with an 87.5% morbidity (organ space infection 58.3%, re-intubation 12.5%, reoperation 25% and septic shock 25%), 8.3% 30-day mortality and 18.2% in-hospital mortality.A synchronous hemihepatectomy (or trisectionectomy) with PD remains a highly morbid combination and should be reserved for patients who have undergone extremely cautious selection.

  View details for DOI 10.1111/hpb.12426

  View details for PubMedID 26058463

• Pancreatectomy with vein reconstruction: technique matters. HPB Dua, M. M., Tran, T. B., Klausner, J., Hwa, K. J., Poultsides, G. A., Norton, J. A., Visser, B. C. 2015; 17 (9): 824-831

  Abstract

  A variety of techniques have been described for portal vein (PV) and/or superior mesenteric vein (SMV) resection/reconstruction during a pancreatectomy. The ideal strategy remains unclear.Patients who underwent PV/SMV resection/reconstruction during a pancreatectomy from 2005 to 2014 were identified. Medical records and imaging were retrospectively reviewed for operative details and outcomes, with particular emphasis on patency.Ninety patients underwent vein resection/reconstruction with one of five techniques: (i) longitudinal venorrhaphy (LV, n = 17); (ii) transverse venorrhaphy (TV, n = 9); (iii) primary end-to-end (n = 28); (iv) patch venoplasty (PV, n = 17); and (v) interposition graft (IG, n = 19). With a median follow-up of 316 days, thrombosis was observed in 16/90 (18%). The rate of thrombosis varied according to technique. All patients with primary end-to-end or TV remained patent. LV, PV and IG were all associated with significant rates of thrombosis (P = 0.001 versus no thrombosis). Comparing thrombosed to patent, there were no differences with respect to pancreatectomy type, pre-operative knowledge of vein involvement and neoadjuvant therapy. Prophylactic aspirin was used in 69% of the total cohort (66% of patent, 81% of thrombosed) and showed no protective benefit.Primary end-to-end and TV have superior patency than the alternatives after PV/SMV resection and should be the preferred techniques for short (<3 cm) reconstructions.

  View details for DOI 10.1111/hpb.12463

  View details for PubMedID 26223388

• Pancreatectomy with vein reconstruction: technique matters HPB Dua, M. M., Tran, T. B., Klausner, J., Hwa, K. J., Poultsides, G. A., Norton, J. A., Visser, B. C. 2015; 17 (9): 824-831

  Abstract

  A variety of techniques have been described for portal vein (PV) and/or superior mesenteric vein (SMV) resection/reconstruction during a pancreatectomy. The ideal strategy remains unclear.Patients who underwent PV/SMV resection/reconstruction during a pancreatectomy from 2005 to 2014 were identified. Medical records and imaging were retrospectively reviewed for operative details and outcomes, with particular emphasis on patency.Ninety patients underwent vein resection/reconstruction with one of five techniques: (i) longitudinal venorrhaphy (LV, n = 17); (ii) transverse venorrhaphy (TV, n = 9); (iii) primary end-to-end (n = 28); (iv) patch venoplasty (PV, n = 17); and (v) interposition graft (IG, n = 19). With a median follow-up of 316 days, thrombosis was observed in 16/90 (18%). The rate of thrombosis varied according to technique. All patients with primary end-to-end or TV remained patent. LV, PV and IG were all associated with significant rates of thrombosis (P = 0.001 versus no thrombosis). Comparing thrombosed to patent, there were no differences with respect to pancreatectomy type, pre-operative knowledge of vein involvement and neoadjuvant therapy. Prophylactic aspirin was used in 69% of the total cohort (66% of patent, 81% of thrombosed) and showed no protective benefit.Primary end-to-end and TV have superior patency than the alternatives after PV/SMV resection and should be the preferred techniques for short (<3 cm) reconstructions.

  View details for DOI 10.1111/hpb.12463

  View details for Web of Science ID 000359853800013

  View details for PubMedCentralID PMC4557658

• Hepato-pancreatectomy: how morbid? Results from the national surgical quality improvement project HPB Tran, T. B., Dua, M. M., Spain, D. A., Visser, B. C., Norton, J. A., Poultsides, G. A. 2015; 17 (9): 763-769

  Abstract

  Simultaneous resection of both the liver and the pancreas carries significant complexity. The objective of this study was to investigate peri-operative outcomes after a synchronous hepatectomy and pancreatectomy (SHP).The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify patients who underwent SHP. Resections were categorized as '< hemihepatectomy', '≥ hemihepatectomy' (hemihepatectomy and trisectionectomy), 'PD' (pancreaticoduodenectomy and total pancreatectomy) and 'distal' (distal pancreatectomy and enucleation).From 2005 to 2013, 480 patients underwent SHP. Patients were stratified based on the extent of resection: '< hemihepatectomy + distal (n = 224)', '≥ hemihepatectomy + distal' (n = 49), '< hemihepatectomy + PD' (n = 83) and '≥ hemihepatectomy + PD' (n = 24). Although the first three groups had a reasonable and comparable safety profile (morbidity 33-51% and mortality 0-6.6%), the '≥ hemihepatectomy + PD' group was associated with an 87.5% morbidity (organ space infection 58.3%, re-intubation 12.5%, reoperation 25% and septic shock 25%), 8.3% 30-day mortality and 18.2% in-hospital mortality.A synchronous hemihepatectomy (or trisectionectomy) with PD remains a highly morbid combination and should be reserved for patients who have undergone extremely cautious selection.

  View details for DOI 10.1111/hpb.12426

  View details for Web of Science ID 000359853800004

• Prognostic relevance of lymph node ratio and total lymph node count for small bowel adenocarcinoma SURGERY Tran, T. B., Qadan, M., Dua, M. M., Norton, J. A., Poultsides, G. A., Visser, B. C. 2015; 158 (2): 486-493

  Abstract

  Nodal metastasis is a known prognostic factor for small bowel adenocarcinoma. The goals of this study were to evaluate the number of lymph nodes (LNs) that should be retrieved and the impact of lymph node ratio (LNR) on survival.Surveillance, Epidemiology, and End Results was queried to identify patients with small bowel adenocarcinoma who underwent resection from 1988 to 2010. Survival was calculated with the Kaplan-Meier method. Multivariate analysis identified predictors of survival.A total of 2,772 patients underwent resection with at least one node retrieved, and this sample included equal numbers of duodenal (n = 1,387) and jejunoileal (n = 1,386) adenocarcinomas. There were 1,371 patients with no nodal metastasis (N0, 49.4%), 928 N1 (33.5%), and 474 N2 (17.1%). The median numbers of LNs examined for duodenal and jejunoileal cancers were 9 and 8, respectively. Cut-point analysis demonstrated that harvesting at least 9 for jejunoileal and 5 LN for duodenal cancers resulted in the greatest survival difference. Increasing LNR at both sites was associated with decreased overall median survival (LNR = 0, 71 months; LNR 0-0.02, 35 months; LNR 0.21-0.4, 25 months; and LNR >0.4, 16 months; P < .001). Multivariate analysis confirmed number of LNs examined, T-stage, LN positivity, and LNR were independent predictors of survival.LNR has a profound impact on survival in patients with small bowel adenocarcinoma. To achieve adequate staging, we recommend retrieving a minimum of 5 LN for duodenal and 9 LN for jejunoileal adenocarcinomas.

  View details for DOI 10.1016/j.surg.2015.03.048

  View details for Web of Science ID 000358108500023

• Prognostic relevance of lymph node ratio and total lymph node count for small bowel adenocarcinoma. Surgery Tran, T. B., Qadan, M., Dua, M. M., Norton, J. A., Poultsides, G. A., Visser, B. C. 2015; 158 (2): 486-93

  Abstract

  Nodal metastasis is a known prognostic factor for small bowel adenocarcinoma. The goals of this study were to evaluate the number of lymph nodes (LNs) that should be retrieved and the impact of lymph node ratio (LNR) on survival.Surveillance, Epidemiology, and End Results was queried to identify patients with small bowel adenocarcinoma who underwent resection from 1988 to 2010. Survival was calculated with the Kaplan-Meier method. Multivariate analysis identified predictors of survival.A total of 2,772 patients underwent resection with at least one node retrieved, and this sample included equal numbers of duodenal (n = 1,387) and jejunoileal (n = 1,386) adenocarcinomas. There were 1,371 patients with no nodal metastasis (N0, 49.4%), 928 N1 (33.5%), and 474 N2 (17.1%). The median numbers of LNs examined for duodenal and jejunoileal cancers were 9 and 8, respectively. Cut-point analysis demonstrated that harvesting at least 9 for jejunoileal and 5 LN for duodenal cancers resulted in the greatest survival difference. Increasing LNR at both sites was associated with decreased overall median survival (LNR = 0, 71 months; LNR 0-0.02, 35 months; LNR 0.21-0.4, 25 months; and LNR >0.4, 16 months; P < .001). Multivariate analysis confirmed number of LNs examined, T-stage, LN positivity, and LNR were independent predictors of survival.LNR has a profound impact on survival in patients with small bowel adenocarcinoma. To achieve adequate staging, we recommend retrieving a minimum of 5 LN for duodenal and 9 LN for jejunoileal adenocarcinomas.

  View details for DOI 10.1016/j.surg.2015.03.048

  View details for PubMedID 26013988

• More with Less: Pancreas-Preserving Total Duodenectomy DIGESTIVE DISEASES AND SCIENCES Qadan, M., Dua, M., Worhunsky, D., Triadafilopoulos, G., Visser, B. 2015; 60 (6): 1565-1568

  View details for DOI 10.1007/s10620-014-3331-z

  View details for PubMedID 25138905

• Cyst Fluid Glucose is Rapidly Feasible and Accurate in Diagnosing Mucinous Pancreatic Cysts. American journal of gastroenterology Zikos, T., Pham, K., Bowen, R., Chen, A. M., Banerjee, S., Friedland, S., Dua, M. M., Norton, J. A., Poultsides, G. A., Visser, B. C., Park, W. G. 2015; 110 (6): 909-914

  Abstract

  Better diagnostic tools are needed to differentiate pancreatic cyst subtypes. A previous metabolomic study showed cyst fluid glucose as a potential marker to differentiate mucinous from non-mucinous pancreatic cysts. This study seeks to validate these earlier findings using a standard laboratory glucose assay, a glucometer, and a glucose reagent strip.Using an IRB-approved prospectively collected bio-repository, 65 pancreatic cyst fluid samples (42 mucinous and 23 non-mucinous) with histological correlation were analyzed.Median laboratory glucose, glucometer glucose, and percent reagent strip positive were lower in mucinous vs. non-mucinous cysts (P<0.0001 for all comparisons). Laboratory glucose<50 mg/dl had a sensitivity of 95% and a specificity of 57% (LR+ 2.19, LR- 0.08). Glucometer glucose<50 mg/dl had a sensitivity of 88% and a specificity of 78% (LR+ 4.05, LR- 0.15). Reagent strip glucose had a sensitivity of 81% and a specificity of 74% (LR+ 3.10, LR- 0.26). CEA had a sensitivity of 77% and a specificity of 83% (LR+ 4.67, LR- 0.27). The combination of having either a glucometer glucose<50 mg/dl or a CEA level>192 had a sensitivity of 100% but a low specificity of 33% (LR+ 1.50, LR- 0.00).Glucose, whether measured by a laboratory assay, a glucometer, or a reagent strip, is significantly lower in mucinous cysts compared with non-mucinous pancreatic cysts.

  View details for DOI 10.1038/ajg.2015.148

  View details for PubMedID 25986360

• Extracorporeal Pringle for laparoscopic liver resection SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Dua, M. M., Worhunsky, D. J., Hwa, K., Poultsides, G. A., Norton, J. A., Visser, B. C. 2015; 29 (6): 1348-1355

  Abstract

  A primary concern during laparoscopic liver resection (lapLR) is hemorrhage during parenchymal transection. Intermittent pedicle clamping is an effective method to minimize blood loss during open liver surgery; however, inflow occlusion techniques are challenging to reproduce during laparoscopy. The purpose of this study is to describe the safety and efficacy of a facile method for Pringle maneuver during lapLR.154 patients who underwent lapLR from 2007 to 2013 were retrospectively reviewed. For Pringle, the hepatoduodenal ligament is encircled with an umbilical tape which is externalized through a flexible Rumel tourniquet running alongside a port used for the operation. The internal end of the catheter is close to the pedicle and the external end is extracorporeal, allowing for easy external occlusion. Patients who underwent Pringle Maneuver (PM, n = 88) were compared to patients who had "No Occlusion" (NO, n = 66) with respect to patient characteristics, operative outcomes, changes in postoperative liver function, and complications.Annual placement of the tourniquet and vascular occlusion increased from 35.7 to 82.8 % (p = 0.004) and 21.4 to 62.1 % (p = 0.02), respectively. Median occlusion time was 24 min (IQR 15-34.3, min 5, max 70). Peak transaminase levels were comparable between groups (AST 298 ± 32 vs 405 ± 47 U/L, p = 0.15; ALT 272 ± 27 vs 372 ± 34 U/L, p = 0.14, NO and PM, respectively). Postoperative transaminase and bilirubin levels for both groups were not significantly different with similar recovery to baseline. Subgroup analysis of cirrhotic patients who underwent Pringle demonstrated similar transaminase profiles compared to non-cirrhotic patients. There were two conversions (1.3 %) and postoperative 30-day mortality was 0.65 %.Extracorporeal tourniquet placement in lapLR is a quick and safe method of gaining control for inflow occlusion. Routine adoption of laparoscopic Pringle maneuver facilitates low conversion rates without liver injury.

  View details for DOI 10.1007/s00464-014-3801-6

  View details for PubMedID 25159645

• Non-MalIg(G4)nant Biliary Obstruction: When the Pill Is Mightier than the Knife DIGESTIVE DISEASES AND SCIENCES Dua, M. M., Qadan, M., Lutchman, G. A., Park, W. G., Triadafilopoulos, G., Visser, B. C. 2015; 60 (5): 1178-1182

  View details for DOI 10.1007/s10620-014-3329-6

  View details for PubMedID 25138904

• Early vein reconstruction and right-to-left dissection for left-sided pancreatic tumors with portal vein occlusion. Journal of gastrointestinal surgery Cloyd, J. M., Dua, M. M., Visser, B. C. 2014; 18 (11): 2034-2037

  Abstract

  Large left-sided pancreatic tumors are frequently associated with portal vein (PV) and/or superior mesenteric vein (SMV) occlusion. Traditionally, vein reconstruction is deferred until after removal of the tumor. However, division of venous collaterals, as is done in a typical left-to-right fashion, leads to progressive portal hypertension and increased risk of variceal hemorrhage during the dissection. Conversely, early PV/SMV resection and reconstruction restores mesenteric-portal flow and decompresses varices, thereby enabling a safer and easier right-to-left pancreatic resection. This "How I Do It" report describes the technique and advantages of a "reconstruction-first" approach for large left-sided pancreatic tumors with venous involvement and left-sided portal hypertension.

  View details for DOI 10.1007/s11605-014-2616-z

  View details for PubMedID 25091848

• Laparoscopic Transgastric Necrosectomy for the Management of Pancreatic Necrosis JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Worhunsky, D. J., Qadan, M., Dua, M. M., Park, W. G., Poultsides, G. A., Norton, J. A., Visser, B. C. 2014; 219 (4): 735-743

  Abstract

  Traditional open necrosectomy for pancreatic necrosis is associated with significant morbidity and mortality. Although minimally invasive techniques have been described and offer some promise, each has considerable limitations. This study assesses the safety and effectiveness of laparoscopic transgastric necrosectomy (LTN), a novel technique for the management of necrotizing pancreatitis.Between 2009 and 2013, patients with retrogastric pancreatic necrosis requiring debridement were evaluated for LTN. Debridement was performed via a laparoscopic transgastric approach using 2 to 3 ports and the wide cystgastrostomy left open. Patient demographics, disease severity, operative characteristics, and outcomes were collected and analyzed.Twenty-one patients (13 men, median age 54 years; interquartile range [IQR] 46 to 62 years) underwent LTN during the study period. The duration between pancreatitis onset and debridement was 65 days (IQR 53 to 124 years). Indications for operation included infection (7 patients) and persistent unwellness (14 patients). Median duration of LTN was 170 minutes (IQR 136 to 199 minutes); there were no conversions. Control of the necrosis was achieved via the single procedure in 19 of 21 patients. Median postoperative hospital stay was 5 days (IQR 3 to 14 days) and the majority (71%) of patients experienced no (n = 9) or only minor postoperative complications (n = 6) by Clavien-Dindo grade. Complications of Clavien-Dindo grade 3 or higher developed in 6 patients, including 1 death (5%). With a median follow-up of 11 months (IQR 7 to 22 months), none of the patients required additional operative debridement or had pancreatic/enteric fistulae or wound complications develop.Laparoscopic transgastric necrosectomy is a novel, minimally invasive technique for the management of pancreatic necrosis that allows for debridement in a single operation. When feasible, LTN can reduce the morbidity associated with traditional open necrosectomy and avoid the limitations of other minimally invasive approaches.

  View details for DOI 10.1016/j.jamcollsurg.2014.04.012

  View details for Web of Science ID 000342422500018

• Laparoscopic transgastric necrosectomy for the management of pancreatic necrosis. Journal of the American College of Surgeons Worhunsky, D. J., Qadan, M., Dua, M. M., Park, W. G., Poultsides, G. A., Norton, J. A., Visser, B. C. 2014; 219 (4): 735-743

  Abstract

  Traditional open necrosectomy for pancreatic necrosis is associated with significant morbidity and mortality. Although minimally invasive techniques have been described and offer some promise, each has considerable limitations. This study assesses the safety and effectiveness of laparoscopic transgastric necrosectomy (LTN), a novel technique for the management of necrotizing pancreatitis.Between 2009 and 2013, patients with retrogastric pancreatic necrosis requiring debridement were evaluated for LTN. Debridement was performed via a laparoscopic transgastric approach using 2 to 3 ports and the wide cystgastrostomy left open. Patient demographics, disease severity, operative characteristics, and outcomes were collected and analyzed.Twenty-one patients (13 men, median age 54 years; interquartile range [IQR] 46 to 62 years) underwent LTN during the study period. The duration between pancreatitis onset and debridement was 65 days (IQR 53 to 124 years). Indications for operation included infection (7 patients) and persistent unwellness (14 patients). Median duration of LTN was 170 minutes (IQR 136 to 199 minutes); there were no conversions. Control of the necrosis was achieved via the single procedure in 19 of 21 patients. Median postoperative hospital stay was 5 days (IQR 3 to 14 days) and the majority (71%) of patients experienced no (n = 9) or only minor postoperative complications (n = 6) by Clavien-Dindo grade. Complications of Clavien-Dindo grade 3 or higher developed in 6 patients, including 1 death (5%). With a median follow-up of 11 months (IQR 7 to 22 months), none of the patients required additional operative debridement or had pancreatic/enteric fistulae or wound complications develop.Laparoscopic transgastric necrosectomy is a novel, minimally invasive technique for the management of pancreatic necrosis that allows for debridement in a single operation. When feasible, LTN can reduce the morbidity associated with traditional open necrosectomy and avoid the limitations of other minimally invasive approaches.

  View details for DOI 10.1016/j.jamcollsurg.2014.04.012

  View details for PubMedID 25158913

• Evaluating the Revised International Consensus Guidelines for Management of Pancreatic Cysts Sighinolfi, M., Quan, S., Dua, M., Poultsides, G., Visser, B., Park, W. NATURE PUBLISHING GROUP. 2014: S86

  View details for Web of Science ID 000344383100279

• Rapid Point-of-Care Measurement of Cyst Fluid Glucose Is Feasible and Accurate in Predicting Mucinous Pancreatic Cysts Zikos, T., Pham, K., Chen, A., Banerjee, S., Friedland, S., Dua, M., Norton, J., Poultsides, G., Visser, B., Park, W. NATURE PUBLISHING GROUP. 2014: S86

  View details for Web of Science ID 000344383100280

• Getting the dead out: modern treatment strategies for necrotizing pancreatitis. Digestive diseases and sciences Dua, M. M., Worhunsky, D. J., Amin, S., Louie, J. D., Park, W. G., Triadafilopoulos, G., Visser, B. C. 2014; 59 (9): 2069-2075

  View details for DOI 10.1007/s10620-014-3153-z

  View details for PubMedID 24748229

• Laparoscopic spleen-preserving distal pancreatectomy: the technique must suit the lesion. Journal of gastrointestinal surgery Worhunsky, D. J., Zak, Y., Dua, M. M., Poultsides, G. A., Norton, J. A., Visser, B. C. 2014; 18 (8): 1445-1451

  Abstract

  Splenic preservation is currently recommended during minimally invasive surgery for benign tumors of the distal pancreas. The aim of this study was to evaluate the outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy, with particular attention paid to the technique used for spleen preservation (splenic vessel ligation vs preservation). A review of consecutive patients who underwent laparoscopic distal pancreatectomy with the intention of splenic preservation was conducted. Patient demographics, operative data, and outcomes were collected and analyzed. Fifty-five consecutive patients underwent laparoscopic distal pancreatectomy with the intention of splenic preservation; 5 required splenectomy (9 %). Of the remaining 50 patients, 31 (62 %) had splenic vessel ligation, and 19 (38 %) had vessel preservation. Patient demographics and tumor size were similar. The vessel ligation group had significantly more pancreas removed (95 vs 52 mm, P < 0.001) and longer operative times (256 vs 201 min, P = 0.008). Postoperative outcomes, complication rates, and splenic viability were similar between groups. Laparoscopic spleen-preserving distal pancreatectomy is a safe operation with a high rate of success (91 %). Vessel ligation was the chosen technical strategy for lesions that required resection of a greater length of pancreas. We found no advantage to either technique with respect to outcomes and splenic preservation. Operative approach should reflect technical considerations including location in the pancreas.

  View details for DOI 10.1007/s11605-014-2561-x

  View details for PubMedID 24939598

• Laparoscopic Bariatric Surgery Can Be Performed Through a Single Incision: A Comparative Study. Obesity surgery Rogula, T., Daigle, C., Dua, M., Shimizu, H., Davis, J., Lavryk, O., Aminian, A., Schauer, P. 2014

  Abstract

  The application of single-incision laparoscopic surgery (SILS) in bariatric patients has been limited to less complex procedures. We evaluated the short-term outcomes of SILS sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), compared to a group of well-established minimally invasive techniques.Twenty-eight morbidly obese patients who underwent SILS SG (n = 14) and RYGB (n = 14) were compared to a matched control group composed of 28 cases of conventional laparoscopic surgery (CLS). A single vertical 2.5-3-cm intra-umbilical incision, three-ports placed trans-fascially, and a liver suspension technique were used to perform SILS.Both groups were comparable in terms of age (p = 0.96), gender (p = 1.0), type of procedure (p = 1.0), and number of comorbidities (p = 0.63). Two (7 %) SILS patients required placement of one additional port, and no conversions to CLS or open surgery were needed. The estimated blood loss (p = 0.48), operative time (p = 0.33), length of hospital stay (p = 0.79), overall 90-day perioperative complication rate (p = 1.0), and short-term weight loss (p = 0.53) were comparable between the two groups. In terms of pain control, the frequency of patient-controlled analgesia use in both groups was similar. However, the pain score (assessed by visual analog scale) was significantly less for SILS patients on postoperative days 1 (5.0 ± 2.1 vs. 6.5 ± 1.8; p = 0.007) and 2 (4.0 ± 2.0 vs. 5.1 ± 2.4; p = 0.49). Cosmetic satisfaction with the scar was high in the SILS group. No patients required reoperation or readmission during the 90 days after surgery.SILS is feasible in carefully selected bariatric patients and results in short-term outcomes comparable to those observed after CLS. Improved pain and cosmesis are potential benefits of SILS.

  View details for DOI 10.1007/s11695-014-1291-1

  View details for PubMedID 24817374

• Intraoperative imaging of nipple perfusion patterns and ischemic complications in nipple-sparing mastectomies. Annals of surgical oncology Wapnir, I., Dua, M., Kieryn, A., Paro, J., Morrison, D., Kahn, D., Meyer, S., Gurtner, G. 2014; 21 (1): 100-106

  Abstract

  Nipple-sparing mastectomies (NSM) have gained acceptance in the field of breast oncology. Ischemic complications involving the nipple-areolar complex (NAC) occur in 3-37 % of cases. Skin perfusion can be monitored intraoperatively using indocyanine green (IC-GREEN™, ICG) and a specialized infrared camera-computer system (SPY Elite™). The blood flow pattern to the breast skin and the NAC were evaluated and a classification scheme was developed.Preincision baseline and postmastectomy skin perfusion studies were performed intraoperatively using 3 mL of ICG. The pattern of arterial blood inflow was classified according to whether perfusion appeared to originate predominantly from the underlying breast tissue (V1), the surrounding skin (V2), or a combination of V1 and V2 (V3). Ischemia, resection, or delayed complications of NAC were recorded.Thirty-nine breasts were interrogated. Seven (18 %) demonstrated a V1 pattern, 18 (46 %) a V2 pattern, and 14 (36 %) a V3 pattern. Seven (18 %) NACs were removed; six intraoperatively and the seventh in a delayed fashion. Notably, five of the seven resected NACs had a V1 pattern. Overall, 71 % of all V1 cases demonstrated profound ischemic changes by intraoperative clinical judgment and SPY imaging. The rates of resection of the NAC differed significantly between perfusion patterns (Fisher's exact test, p = 0.0003).Three perfusion patterns for the NAC are defined. The V1 pattern had the highest rate of NAC ischemia in NSM. Imaging NAC and skin perfusion during NSMs is a useful adjunctive tool with potential to direct placement of mastectomy incisions and minimize ischemic complications.

  View details for DOI 10.1245/s10434-013-3214-0

  View details for PubMedID 24046104

• Cardiac metastases and tumor embolization: A rare sequelae of primary undifferentiated liver sarcoma. International journal of surgery case reports Dua, M. M., Cloyd, J. M., Haddad, F., Beygui, R. E., Norton, J. A., Visser, B. C. 2014; 5 (12): 927-931

  Abstract

  Primary hepatic sarcomas are uncommon malignant neoplasms; prognostic features, natural history, and optimal management of these tumors are not well characterized.This report describes the management of a 51-year-old patient that underwent a right trisectionectomy for a large hepatic mass found to be a liver sarcoma on pathology. He subsequently developed tumor emboli to his lungs and was discovered to have cardiac intracavitary metastases from his primary tumor. The patient underwent cardiopulmonary bypass and resection of the right-sided heart metastases to prevent further pulmonary sequela of tumor embolization.The lack of distinguishing symptoms or imaging characteristics that clearly define hepatic sarcomas makes it challenging to achieve a diagnosis prior to pathologic examination. Metastatic spread is frequently to the lung or pleura, but very rarely seen within the heart. Failure to recognize cardiac metastatic disease will ultimately lead to progressive tumor embolization and cardiac failure if left untreated.The most effective therapy for primary liver sarcomas is surgery; radical resection should be performed if possible given the aggressive nature of these tumors to progress and metastasize.

  View details for DOI 10.1016/j.ijscr.2014.10.004

  View details for PubMedID 25460438

• RGD-Conjugated Human Ferritin Nanoparticles for Imaging Vascular Inflammation and Angiogenesis in Experimental Carotid and Aortic Disease MOLECULAR IMAGING AND BIOLOGY Kitagawa, T., Kosuge, H., Uchida, M., Dua, M. M., Iida, Y., Dalman, R. L., Douglas, T., McConnell, M. V. 2012; 14 (3): 315-324

  Abstract

  Inflammation and angiogenesis are important contributors to vascular disease. We evaluated imaging both of these biological processes, using Arg-Gly-Asp (RGD)-conjugated human ferritin nanoparticles (HFn), in experimental carotid and abdominal aortic aneurysm (AAA) disease.Macrophage-rich carotid lesions were induced by ligation in hyperlipidemic and diabetic FVB mice (n = 16). AAAs were induced by angiotensin II infusion in apoE(-/-) mice (n=10). HFn, with or without RGD peptide, was labeled with Cy5.5 and injected intravenously for near-infrared fluorescence imaging.RGD-HFn showed significantly higher signal than HFn in diseased carotids and AAAs relative to non-diseased regions, both in situ (carotid: 1.88 ± 0.30 vs. 1.17 ± 0.10, p = 0.04; AAA: 2.59 ± 0.24 vs. 1.82 ± 0.16, p = 0.03) and ex vivo. Histology showed RGD-HFn colocalized with macrophages in carotids and both macrophages and neoangiogenesis in AAA lesions.RGD-HFn enhances vascular molecular imaging by targeting both vascular inflammation and angiogenesis, and allows more comprehensive detection of high-risk atherosclerotic and aneurysmal vascular diseases.

  View details for DOI 10.1007/s11307-011-0495-1

  View details for PubMedID 21638084

• Bioluminescence and Magnetic Resonance Imaging of Macrophage Homing to Experimental Abdominal Aortic Aneurysms MOLECULAR IMAGING Miyama, N., Dua, M. M., Schultz, G. M., Kosuge, H., Terashima, M., Pisani, L. J., Dalman, R. L., McConnell, M. V. 2012; 11 (2): 126-134

  Abstract

  Macrophage infiltration is a prominent feature of abdominal aortic aneurysm (AAA) progression. We used a combined imaging approach with bioluminescence (BLI) and magnetic resonance imaging (MRI) to study macrophage homing and accumulation in experimental AAA disease. Murine AAAs were created via intra-aortic infusion of porcine pancreatic elastase. Mice were imaged over 14 days after injection of prepared peritoneal macrophages. For BLI, macrophages were from transgenic mice expressing luciferase. For MRI, macrophages were labeled with iron oxide particles. Macrophage accumulation during aneurysm progression was observed by in situ BLI and by in vivo 7T MRI. Mice were sacrificed after imaging for histologic analysis. In situ BLI (n  =  32) demonstrated high signal in the AAA by days 7 and 14, which correlated significantly with macrophage number and aortic diameter. In vivo 7T MRI (n  =  13) at day 14 demonstrated T₂* signal loss in the AAA and not in sham mice. Immunohistochemistry and Prussian blue staining confirmed the presence of injected macrophages in the AAA. BLI and MRI provide complementary approaches to track macrophage homing and accumulation in experimental AAAs. Similar dual imaging strategies may aid the study of AAA biology and the evaluation of novel therapies.

  View details for DOI 10.2310/7290.2011.00033

  View details for PubMedID 22469240

• Surgery for Thoracic Outlet Syndrome: A Nationwide Perspective Vascular Annual Meeting of the Society-for-Vascular-Surgery Lee, J. T., Dua, M. M., Chandra, V., Hernandez-Boussard, T. M., Illig, K. A. MOSBY-ELSEVIER. 2011: 100S–101S

  View details for Web of Science ID 000291410700194

• Hyperglycemia limits experimental aortic aneurysm progression JOURNAL OF VASCULAR SURGERY Miyama, N., Dua, M. M., Yeung, J. J., Schultz, G. M., Asagami, T., Sho, E., Sho, M., Dalman, R. L. 2010; 52 (4): 975-983

  Abstract

  Diabetes mellitus (DM) is associated with reduced progression of abdominal aortic aneurysm (AAA) disease. Mechanisms responsible for this negative association remain unknown. We created AAAs in hyperglycemic mice to examine the influence of serum glucose concentration on experimental aneurysm progression.Aortic aneurysms were induced in hyperglycemic (DM) and normoglycemic models by using intra-aortic porcine pancreatic elastase (PPE) infusion in C57BL/6 mice or by systemic infusion of angiotensin II (ANG) in apolipoprotein E-deficient (ApoE(-/-)) mice, respectively. In an additional DM cohort, insulin therapy was initiated after aneurysm induction. Aneurysmal aortic enlargement progression was monitored with serial transabdominal ultrasound measurements. At sacrifice, AAA cellularity and proteolytic activity were evaluated by immunohistochemistry and substrate zymography, respectively. Influences of serum glucose levels on macrophage migration were examined in separate models of thioglycollate-induced murine peritonitis.At 14 days after PPE infusion, AAA enlargement in hyperglycemic mice (serum glucose ≥ 300 mg/dL) was less than that in euglycemic mice (PPE-DM: 54% ± 19% vs PPE: 84% ± 24%, P < .0001). PPE-DM mice also demonstrated reduced aortic mural macrophage infiltration (145 ± 87 vs 253 ± 119 cells/cross-sectional area, P = .0325), elastolysis (% residual elastin: 20% ± 7% vs 12% ± 6%, P = .0209), and neovascularization (12 ± 8 vs 20 ± 6 vessels/high powered field, P = .0229) compared with PPE mice. Hyperglycemia limited AAA enlargement after ANG infusion in ApoE(-/-) mice (ANG-DM: 38% ± 12% vs ANG: 61% ± 37% at day 28). Peritoneal macrophage production was reduced in response to thioglycollate stimulation in hyperglycemic mice, with limited augmentation noted in response to vascular endothelial growth factor administration. Insulin therapy reduced serum glucose levels and was associated with AAA enlargement rates intermediate between euglycemic and hyperglycemic mice (PPE: 1.21 ± 0.14 mm vs PPE-DM: 1.00 ± 0.04 mm vs PPE-DM + insulin: 1.14 ± 0.05 mm).Hyperglycemia reduces progression of experimental AAA disease; lowering of serum glucose levels with insulin treatment diminishes this protective effect. Identifying mechanisms of hyperglycemic aneurysm inhibition may accelerate development of novel clinical therapies for AAA disease.

  View details for DOI 10.1016/j.jvs.2010.05.086

  View details for Web of Science ID 000282660300023

  View details for PubMedID 20678880

  View details for PubMedCentralID PMC2987703

• Live Transference of Surgical Subspecialty Skills Using Telerobotic Proctoring to Remote General Surgeons JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Ereso, A. Q., Garcia, P., Tseng, E., Gauger, G., Kim, H., Dua, M. M., Victorino, G. P., Guy, T. S. 2010; 211 (3): 400-411

  Abstract

  Certain clinical environments, including military field hospitals or rural medical centers, lack readily available surgical subspecialists. We hypothesized that telementoring by a surgical subspecialist using a robotic platform is feasible and can convey subspecialty knowledge and skill to a remotely located general surgeon.Eight general surgery residents evaluated the effect of remote surgical telementoring by performing 3 operative procedures, first unproctored and then again when teleproctored by a surgical subspecialist. The clinical scenarios consisted of a penetrating right ventricular injury requiring suture repair, an open tibial fracture requiring external fixation, and a traumatic subdural hematoma requiring craniectomy. A robotic platform consisting of a pan-and-tilt camera with laser pointer attached to an overhead surgical light with integrated audio allowed surgical subspecialists the ability to remotely teleproctor residents. Performance was evaluated using an Operative Performance Scale. Satisfaction surveys were given after performing the scenario unproctored and again after proctoring.Overall mean performance scores were superior in all scenarios when residents were proctored than when they were not (4.30 +/- 0.25 versus 2.43 +/- 0.20; p < 0.001). Mean performance scores for individual metrics, including tissue handling, instrument handling, speed of completion, and knowledge of anatomy, were all superior when residents were proctored (p < 0.001). Satisfaction surveys showed greater satisfaction and comfort among residents when proctored. Proctored residents believed the robotic platform facilitated learning and would be feasible if used clinically.This study supports the use of surgical teleproctoring in guiding remote general surgeons by a surgical subspecialist in the care of a wounded patient in need of an emergency subspecialty operation.

  View details for DOI 10.1016/j.jamcollsurg.2010.05.014

  View details for Web of Science ID 000281708500014

  View details for PubMedID 20800198

• Hyperglycemia modulates plasminogen activator inhibitor-1 expression and aortic diameter in experimental aortic aneurysm disease SURGERY Dua, M. M., Miyama, N., Azuma, J., Schultz, G. M., Sho, M., Morser, J., Dalman, R. L. 2010; 148 (2): 429-435

  Abstract

  Extracellular matrix degradation is a sentinel pathologic feature of abdominal aortic aneurysm (AAA) disease. Diabetes mellitus, a negative risk factor for AAA, may impair aneurysm progression through its influence on the fibrinolytic system. We hypothesize that hyperglycemia limits AAA progression through effects on endogenous plasminogen activator inhibitor-1 (PAI-1) levels and subsequent reductions in plasmin generation.Experimental AAAs were induced in diabetic and control mice via the intra-aortic elastase infusion method. Serial transabdominal high-frequency ultrasound examinations were performed to monitor aortic diameter following elastase infusion. Circulating PAI-1 and plasmin alpha2-antiplasmin (PAP) complex concentrations were determined by ELISA and local expression of PAI-1 levels was examined by RT-PCR and immunohistochemistry.Hyperglycemia was associated with reduced AAA diameter, increased plasma PAI-1 concentration and reduced plasmin generation. Aneurysmal aortic PAI-1 gene expression increased in parallel with plasma concentration, with peak expression occurring early after aneurysm initiation.Hyperglycemia increases PAI-1 expression and attenuates AAA diameter in experimental AAA disease. These results emphasize the role of the fibrinolytic pathway in AAA pathophysiology, and suggest a candidate mechanism for hyperglycemic inhibition of AAA disease.

  View details for DOI 10.1016/j.surg.2010.05.014

  View details for Web of Science ID 000280433200034

  View details for PubMedID 20561659

  View details for PubMedCentralID PMC2905480

• Candidate Compounds for Drug-Device Hybrid Therapies in the Management of Abdominal Aortic Aneurysm (AAA) Disease Iida, Y., Schultz, G. M., Dua, M. M., Miyama, N., Peterson, S., Sulaimon, S., Dalman, R. L. MOSBY-ELSEVIER. 2010: 530

  View details for DOI 10.1016/j.jvs.2010.05.044

  View details for Web of Science ID 000280455900071

• Hemodynamic Influences on abdominal aortic aneurysm disease: Application of biomechanics to aneurysm pathophysiology VASCULAR PHARMACOLOGY Dua, M. M., Dalman, R. L. 2010; 53 (1-2): 11-21

  Abstract

  "Atherosclerotic" abdominal aortic aneurysms (AAAs) occur with the greatest frequency in the distal aorta. The unique hemodynamic environment of this area predisposes it to site-specific degenerative changes. In this review, we summarize the differential hemodynamic influences present along the length of the abdominal aorta, and demonstrate how alterations in aortic flow and wall shear stress modify AAA progression in experimental models. Improved understanding of aortic hemodynamic risk profiles provides an opportunity to modify patient activity patterns to minimize the risk of aneurysmal degeneration.

  View details for DOI 10.1016/j.vph.2010.03.004

  View details for Web of Science ID 000278450300002

  View details for PubMedID 20347049

  View details for PubMedCentralID PMC2880166

• In vivo Targeted Molecular Imaging of Matrix Metalloproteinase Inhibition in Experimental Abdominal Aortic Aneurysm Disease 82nd National Conference and Exhibitions and Scientific Sessions of the American-Heart-Association Dua, M. M., Schultz, G. M., Miyama, N., Peterson, J. D., Dalman, R. L. LIPPINCOTT WILLIAMS & WILKINS. 2009: S358–S359

  View details for Web of Science ID 000271831500236

• Lipoxin A(4) Attenuates Microvascular Fluid Leak During Inflammation 70th Annual Meeting of the Society-of-University-Surgeons/4th Annual Academic Surgical Congress Ereso, A. Q., Cureton, E. L., Cripps, M. W., Sadjadi, J., Dua, M. M., Curran, B., Victorino, G. P. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2009: 183–88

  Abstract

  The release of proinflammatory cytokines during inflammation disturbs the endothelial barrier and can initiate significant intravascular volume loss. Proinflammatory cytokines also induce the expression of anti-inflammatory mediators, such as lipoxin, which promote the resolution of inflammation. Our hypothesis is that lipoxin A(4) (LXA(4)) reverses the increased microvascular fluid leak observed during inflammatory conditions.Microvascular fluid leak (L(p)) was measured in rat mesenteric venules using a micro-cannulation technique. L(p) was measured under the following conditions: (1) LXA(4) (100 nM) alone (n = 5), (2) LXA(4) (100 nM) administered after endothelial hyperpermeability induced by a continuous perfusion of 10 nM platelet activating factor (PAF) (n = 5), (3) LXA(4) (100 nM) perfused after inflammation induced by a systemic bolus of 10 mg/kg lipopolysaccharide (LPS) (n = 5), and (4) LXA(4) (100 nM) perfused after LPS-induced inflammation during inhibition of c-Jun N-terminal kinase (n = 4).LXA(4) alone slightly increased L(p) from baseline (L(p)-baseline = 1.05 +/- 0.03, L(p)-LXA(4) = 1.55 +/- 0.04; P < 0.0001). PAF increased L(p) 4-fold (L(p)-baseline = 1.20 +/- 0.10, L(p)-PAF = 4.49 +/- 0.95; P < 0.0001). LXA(4) administration after PAF decreased L(p) 66% versus PAF alone (from 4.49 +/- 0.95 to 1.54 +/- 0.13; P = 0.0004). LPS-induced inflammation increased L(p) over 2-fold (L(p)-baseline = 1.05 +/- 0.03, L(p)-LPS = 2.27 +/- 0.13; P < 0.0001). LXA(4) administration after LPS decreased L(p) 42% versus LPS alone (from 2.27 +/- 0.13 to 1.31 +/- 0.05; P < 0.0001). The effect of c-Jun N-terminal kinase inhibition during LPS-induced inflammation attenuated the decrease in leak cause by LXA(4) by 51% (P = 0.0002).After either LPS or PAF, LXA(4) attenuated the intravascular volume loss caused by these inflammatory mediators. The activity of LXA(4) may be partly mediated by the c-Jun N-terminal kinase signaling pathway. These data support an anti-inflammatory role for LXA(4) and suggests a potential pharmacologic role for LXA(4) during inflammation.

  View details for DOI 10.1016/j.jss.2009.01.009

  View details for Web of Science ID 000270564300002

  View details for PubMedID 19524267

• In Vivo MR Imaging of Iron Oxide-Labeled Macrophages in Experimental Abdominal Aortic Aneurysms (AAAs) Dua, M. M., Miyama, N., Kosuge, H., Terashima, M., Dalman, R. L. LIPPINCOTT WILLIAMS & WILKINS. 2009: E98

  View details for Web of Science ID 000267102500466

• Usability of Robotic Platforms for Remote Surgical Teleproctoring TELEMEDICINE JOURNAL AND E-HEALTH Ereso, A. Q., Garcia, P., Tseng, E., Dua, M. M., Victorino, G. P., Guy, T. S. 2009; 15 (5): 445-453

  Abstract

  Military field hospitals and rural medical centers may lack surgical subspecialists. Robotic technology can enable proctoring of remotely located general surgeons by subspecialists. Our objective compared three proctoring platforms: (1) 6-degree-of-freedom (DOF) computer input devices controlling a camera and laser pointer mounted on robotic arms, (2) a computer mouse controlling a pan-tilt-zoom (PTZ) camera and robotic laser scanner, and (3) a computer pen/tablet controlling a PTZ-camera and robotic laser scanner. Our hypothesis was that a pen/tablet or mouse platform would be superior to the 6-DOF-input device platform. Five surgeons used each platform by simulating the creation of operative incisions. Qualitative (instrument handling, time, motion, spatial awareness) and quantitative performance (accuracy, speed) was assessed on a five-point scale. Each surgeon completed a satisfaction survey. Both mouse and pen/tablet had higher mean performance scores than the 6-DOF-input device in all quantitative (6-DOF = 1.7 +/- 0.8, mouse = 4.3 +/- 0.2, pen = 4.1 +/- 0.6; p < 0.001) and qualitative measures (6-DOF = 1.7 +/- 0.2, mouse = 4.8 +/- 0.0, pen = 4.6 +/- 0.1; p < 0.001). Handling, motion, and instrument awareness were superior with the mouse and pen/tablet versus 6-DOF-input devices (p < 0.0001). Speed and accuracy were also superior using the mouse or pen/tablet versus 6-DOF-input devices (p < 0.0001). Surgeons completed tasks faster using the mouse versus pen/tablet (p = 0.02). Satisfaction surveys revealed a preference for the mouse. This study demonstrates the superiority of a mouse or pen/tablet controlling a PTZ-camera and robotic laser scanner for remote surgical teleproctoring versus 6-DOF-input devices controlling a camera and laser pointer. Either a mouse or pen/tablet platform allows subspecialists to proctor remotely located surgeons.

  View details for DOI 10.1089/tmj.2008.0164

  View details for Web of Science ID 000267334300008

  View details for PubMedID 19548825

• Identifying abdominal aortic aneurysm risk factors in postmenopausal women. Women's health (London, England) Dua, M. M., Dalman, R. L. 2009; 5 (1): 33-37

  Abstract

  Evaluation of: Lederle FA, Larson JC, Margolis KL et al.: Abdominal aortic aneurysm events in the Women's Health Initiative: cohort study. Br. Med. J. 337, A1724 (2008). A linked cohort study of 161,808 postmenopausal women aged 50-79 years enrolled in the Women's Health Initiative was conducted during which participants were followed for the incidence of abdominal aortic aneurysm repair or rupture. This study evaluated the association between potential risk factors and subsequent abdominal aortic aneurysm events in women. A total of 467 women reported a diagnosis of abdominal aortic aneurysm before entering the study or during participation, with 184 aneurysm-related events identified. Abdominal aortic aneurysm events were strongly associated with age and smoking and negatively associated with diabetes and baseline use of postmenopausal hormone supplementation. Previous studies investigating abdominal aortic aneurysm have focused primarily on men, with little reliable information available on women. This study contributes a large female cohort to provide better insight into gender-specific abdominal aortic aneurysm risks and disease associations.

  View details for DOI 10.2217/17455057.5.1.33

  View details for PubMedID 19102638

• Evaluation of platybasia with MR imaging 39th Annual Meeting of the American-Society-of-Neuroradiology Koenigsberg, R. A., Vakil, N., Hong, T. A., Htaik, T., Faerber, E., Maiorano, T., Dua, M., FARO, S., Gonzales, C. AMER SOC NEURORADIOLOGY. 2005: 89–92

  Abstract

  Platybasia, or abnormal obtuseness of the basal angle, was first measured on plain skull images. At present, evaluation of the brain and skull more commonly involves CT and MR imaging. We evaluated a new MR imaging method of evaluating platybasia.We retrospectively evaluated midline sagittal MR images in 200 adults and 50 children. The basal angle of the skull base was measured by using two methods: The standard MR imaging technique measured the angle formed by two lines-one joining the nasion and the center of the pituitary fossa connected by a line joining the anterior border of the foramen magnum and center of the pituitary fossa. The modified technique measured the angle formed by a line across the anterior cranial fossa and dorsum sellae connecting a line along the clivus.With the standard MR imaging technique, we obtained mean angles of 129 degrees +/- 6 degrees for adults and 127 degrees +/- 5 degrees for children, compared with 135.3 degrees (composite mean) in previous series. The modified technique produced values of 117 degrees +/- 6 degrees for adults and 114 degrees +/- 5 degrees for children, which were significantly lower that those of standard MR imaging and traditional radiography (P <.05).Both the standard and modified MR imaging techniques produced basal angles lower than those previously reported with standard radiography. The modified technique uses clearly featured landmarks that can be reproduced consistently on midline sagittal T1 images. This technique and its corresponding values can be used as the new standard for evaluating the basal angle.

  View details for Web of Science ID 000226729300021

  View details for PubMedID 15661707