Bio

Clinical Focus


  • Cancer > GI Oncology
  • General Surgery

Academic Appointments


Honors & Awards


  • John Collins Memorial Teaching Award, Annual faculty teaching award selected by entire body of general surgery residents (2010-2011)

Professional Education


  • Residency:Univ of California San Francisco (2005) CA
  • Medical Education:Univ of California San Francisco (1999) CA
  • Fellowship:University of Edinburgh; Edinburgh Royal (2006)
  • Board Certification: General Surgery, American Board of Surgery (2006)
  • MD, Univ. of Calif., San Francisco, Medicine (1999)
  • Resident, Univ. Of Calif., San Francisco, General Surgery (2005)
  • Fellow, Univ. of Edinburgh, UK, Hepatobiliary/Pancreatic Surgery (2006)

Research & Scholarship

Current Research and Scholarly Interests


My research interests span the breath of my clinical practice. Areas of active research include the multidisciplinary treatment of hepatocellular carcinoma, technical aspects of minimally invasive pancreatic and liver surgery, and pre-operative therapy for "borderline" resectable pancreatic cancer (to bring more patients to surgery). I am also investigating trends in the management of hepatobiliary cancers in California, focusing on socioeconomic and instituional barriers to appropriate care.

Clinical Trials


  • Combination SBRT (Stereotactic Body Radiotherapy) With TACE (Transarterial Chemoembolization) for Unresectable Hepatocellular Carcinoma Not Recruiting

    To establish the efficacy and toxicity of TACE combined with SBRT

    Stanford is currently not accepting patients for this trial. For more information, please contact Laurie Ann Columbo, 650-736-0792.

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  • Prognostic Value of Baseline Computed Tomography (CT) Perfusion Parameters of Pancreatic Cancer for Patients Undergoing Stereotactic Body Radiotherapy or Surgical Resection Not Recruiting

    The purpose of this study is first, to determine whether baseline perfusion characteristics of pancreatic cancer, as characterized by CT perfusion studies, can predict tumor response to treatment by stereotactic body radiotherapy (SBRT). The second goal of this study is to determine whether baseline perfusion characteristics in those patients with resectable pancreatic cancer correlate with immunohistologic markers of angiogenesis such as microvessel density and vascular endothelial growth factor (VEGF) expression.

    Stanford is currently not accepting patients for this trial. For more information, please contact Lindee Burton, (650) 725 - 4712.

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  • Transarterial Chemoembolization vs CyberKnife for Recurrent Hepatocellular Carcinoma Not Recruiting

    Primary Objective: To compare the efficacy of TACE vs. CyberKnife SBRT in the treatment of locally recurrent HCC after initial TACE. Secondary Objectives: 1. To determine the progression-free survival of TACE vs. CyberKnife SBRT 2. To determine the overall survival of TACE vs. CyberKnife SBRT for locally recurrent HCC 3. To determine the toxicities associated with TACE or CyberKnife SBRT for the treatment of recurrent HCC.

    Stanford is currently not accepting patients for this trial. For more information, please contact Laurie Ann Columbo, (650) 736 - 0792.

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  • Phase II Gemcitabine + Fractionated Stereotactic Radiotherapy for Unresectable Pancreatic Adenocarcinoma Not Recruiting

    This multi-institutional trial aims to evaluate the potential benefit and side effects of adding fractionated stereotactic body radiotherapy/surgery (SBRT) before and after chemotherapy with gemcitabine for locally advanced pancreatic cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Laurie Ann Columbo, 650-736-0792.

    View full details

Teaching

2013-14 Courses


Publications

Journal Articles


  • Does chronic kidney disease affect outcomes after major abdominal surgery? Results from the national surgical quality improvement program. Journal of gastrointestinal surgery Cloyd, J. M., Ma, Y., Morton, J. M., Kurella Tamura, M., Poultsides, G. A., Visser, B. C. 2014; 18 (3): 605-612

    Abstract

    The impact of chronic kidney disease (CKD) and end-stage renal disease on outcomes following major abdominal surgery is not well defined.The 2008 NSQIP database was queried to identify adult patients undergoing complex abdominal surgery (major colorectal, hepatobiliary, pancreatic, gastric, and esophageal operations). Thirty-day morbidity and mortality in patients on hemodialysis (HD) versus patients not on HD were compared. The impact of preoperative renal insufficiency, measured by glomerular filtration rate (GFR), on morbidity and mortality was then assessed in non-dialysis patients.Of 24,572 patients who underwent major abdominal operations, excluding emergency cases, only 149 (0.6 %) were on HD preoperatively. Thirty-day mortality in the HD group was 12.8 % compared to 1.8 % for those not on HD (p < 0.0001). Overall complication rate was 23.5 versus 12.3 % (p < 0.0001). In particular, rates of pneumonia (6.7 vs 3.0 %, p < 0.05) and sepsis (12.8 vs 5.3 %, p < 0.001) were higher in patients on HD. In patients not on HD, GFR was significantly predictive of postoperative mortality after controlling for age, gender, race, emergency status, and comorbidities. Compared to patients with normal preoperative kidney function (GFR, 75-90 ml/min/1.73 m(2)), even modest CKD (GFR, 45-60 ml/min/1.73 m(2)) was associated with increased postoperative mortality (odds ratio (OR), 1.62). With greater impairment in kidney function, postoperative mortality was even more marked (GFR, 30-45 ml/min/1.73 m(2) and OR, 2.84; GFR, 15-30 ml/min/1.73 m(2) and OR, 5.56). In addition, CKD was independently associated with increased postoperative complications.Any degree of preoperative kidney impairment, even mild asymptomatic disease, is associated with clinically significant increases in 30-day postoperative morbidity and mortality following major abdominal surgery.

    View details for DOI 10.1007/s11605-013-2390-3

    View details for PubMedID 24241964

  • Locally advanced gastric cancer complicated by mesenteric invasion and intestinal malrotation. Digestive diseases and sciences Huang, R. J., Visser, B. C., Chen, A. M., Ladabaum, U. 2014; 59 (2): 267-269

    View details for DOI 10.1007/s10620-013-2869-5

    View details for PubMedID 24036993

  • Reassessment of the Current American Joint Committee on Cancer Staging System for Pancreatic Neuroendocrine Tumors JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Qadan, M., Ma, Y., Visser, B. C., Kunz, P. L., Fisher, G. A., Norton, J. A., Poultsides, G. A. 2014; 218 (2): 188-195

    Abstract

    Adopting a unified staging system for pancreatic neuroendocrine tumors (PNETs) has been challenging. Currently, the American Joint Committee on Cancer (AJCC) recommends use of the pancreatic adenocarcinoma staging system for PNETs. We sought to explore the prognostic usefulness of the pancreatic adenocarcinoma staging system for PNETs.The Surveillance, Epidemiology, and End Results program data were used to identify patients with PNETs who underwent curative-intent surgical resection from 1983 to 2008. The discriminatory ability of the AJCC system was examined and a new TNM system was devised using extent of disease variables.In 1,202 patients identified, lymph node metastasis was associated with worse 10-year overall survival after resection (51% vs 63%; p < 0.0001), as was the presence of distant metastatic disease (35% vs 62%; p < 0.0001). The current AJCC system (recorded by the Surveillance, Epidemiology, and End Results program in 412 patients since 2004) distinguished 5-year overall survival only between stages I and II (p = 0.01), but not between stages II and III (p = 0.97), or stages III and IV (p = 0.36). By modifying the T stage to be based on size alone (0.1 to 1.0 cm, 1.1 to 2.0 cm, 2.1 to 4.0 cm, and >4.0 cm) and revising the TNM subgroups, we propose a novel TNM system with improved discriminatory ability between disease stages (stages I vs II; p = 0.16; II vs III; p < 0.0001; and III vs IV; p = 0.008).In this study evaluating the current AJCC staging system for PNETs, there were no significant differences detected between stages II and III or stages III and IV. We propose a novel TNM system that might better discriminate between outcomes after surgical resection of PNETs.

    View details for DOI 10.1016/j.jamcollsurg.2013.11.001

    View details for Web of Science ID 000329763900008

    View details for PubMedID 24321190

  • Postoperative serum amylase predicts pancreatic fistula formation following pancreaticoduodenectomy. Journal of gastrointestinal surgery Cloyd, J. M., Kastenberg, Z. J., Visser, B. C., Poultsides, G. A., Norton, J. A. 2014; 18 (2): 348-353

    Abstract

    Early identification of patients at risk for developing pancreatic fistula (PF) after pancreaticoduodenectomy (PD) may facilitate prevention or treatment strategies aimed at reducing its associated morbidity.A retrospective review of 176 consecutive PD performed between 2006 and 2011 was conducted in order to analyze the association between the serum amylase on postoperative day 1 (POD1) and the development of PF.Serum amylase was recorded on POD1 in 146 of 176 PD cases (83.0 %). Twenty-seven patients (18.5 %) developed a postoperative PF: 6 type A, 19 type B, and 2 type C. Patients with a PF had a mean serum amylase on POD1 of 659 ± 581 compared to 246 ± 368 in those without a fistula (p < 0.001). On logistic regression, a serum amylase >140 U/L on POD1 was strongly associated with developing a PF (OR, 5.48; 95 % CI, 1.94-15.44). Sensitivity and specificity of a postoperative serum amylase >140 U/L was 81.5 and 55.5 %, respectively. Positive and negative predictive values were 29.3 and 93.0 %, respectively.An elevated serum amylase on POD1 may be used, in addition to other prognostic factors, to help stratify risk for developing PF following PD.

    View details for DOI 10.1007/s11605-013-2293-3

    View details for PubMedID 23903930

  • Gallstone pancreatitis: why not cholecystectomy? JAMA surgery Worhunsky, D. J., Visser, B. C. 2013; 148 (9): 872-?

    View details for DOI 10.1001/jamasurg.2013.3063

    View details for PubMedID 23884335

  • Metabolomic-derived novel cyst fluid biomarkers for pancreatic cysts: glucose and kynurenine GASTROINTESTINAL ENDOSCOPY Park, W. G., Wu, M., Bowen, R., Zheng, M., Fitch, W. L., Pai, R. K., Wodziak, D., Visser, B. C., Poultsides, G. A., Norton, J. A., Banerjee, S., Chen, A. M., Friedland, S., Scott, B. A., Pasricha, P. J., Lowe, A. W., Peltz, G. 2013; 78 (2): 295-?

    Abstract

    BACKGROUND: Better pancreatic cyst fluid biomarkers are needed. OBJECTIVE: To determine whether metabolomic profiling of pancreatic cyst fluid would yield clinically useful cyst fluid biomarkers. DESIGN: Retrospective study. SETTING: Tertiary-care referral center. PATIENTS: Two independent cohorts of patients (n = 26 and n = 19) with histologically defined pancreatic cysts. INTERVENTION: Exploratory analysis for differentially expressed metabolites between (1) nonmucinous and mucinous cysts and (2) malignant and premalignant cysts was performed in the first cohort. With the second cohort, a validation analysis of promising identified metabolites was performed. MAIN OUTCOME MEASUREMENTS: Identification of differentially expressed metabolites between clinically relevant cyst categories and their diagnostic performance (receiver operating characteristic [ROC] curve). RESULTS: Two metabolites had diagnostic significance-glucose and kynurenine. Metabolomic abundances for both were significantly lower in mucinous cysts compared with nonmucinous cysts in both cohorts (glucose first cohort P = .002, validation P = .006; and kynurenine first cohort P = .002, validation P = .002). The ROC curve for glucose was 0.92 (95% confidence interval [CI], 0.81-1.00) and 0.88 (95% CI, 0.72-1.00) in the first and validation cohorts, respectively. The ROC for kynurenine was 0.94 (95% CI, 0.81-1.00) and 0.92 (95% CI, 0.76-1.00) in the first and validation cohorts, respectively. Neither could differentiate premalignant from malignant cysts. Glucose and kynurenine levels were significantly elevated for serous cystadenomas in both cohorts. LIMITATIONS: Small sample sizes. CONCLUSION: Metabolomic profiling identified glucose and kynurenine to have potential clinical utility for differentiating mucinous from nonmucinous pancreatic cysts. These markers also may diagnose serous cystadenomas.

    View details for DOI 10.1016/j.gie.2013.02.037

    View details for Web of Science ID 000321825200015

    View details for PubMedID 23566642

  • Colorectal cancer diagnostics: biomarkers, cell-free DNA, circulating tumor cells and defining heterogeneous populations by single-cell analysis. Expert review of molecular diagnostics Kin, C., Kidess, E., Poultsides, G. A., Visser, B. C., Jeffrey, S. S. 2013; 13 (6): 581-599

    Abstract

    Reliable biomarkers are needed to guide treatment of colorectal cancer, as well as for surveillance to detect recurrence and monitor therapeutic response. In this review, the authors discuss the use of various biomarkers in addition to serum carcinoembryonic antigen, the current surveillance method for metastatic recurrence after resection. The clinical relevance of mutations including microsatellite instability, KRAS, BRAF and SMAD4 is addressed. The role of circulating tumor cells and cell-free DNA with regards to their implementation into clinical use is discussed, as well as how single-cell analysis may fit into a monitoring program. The detection and characterization of circulating tumor cells and cell-free DNA in colorectal cancer patients will not only improve the understanding of the development of metastasis, but may also supplant the use of other biomarkers.

    View details for DOI 10.1586/14737159.2013.811896

    View details for PubMedID 23895128

  • Seventh Edition (2010) of the AJCC/UICC Staging System for Gastric Adenocarcinoma: Is there Room for Improvement? ANNALS OF SURGICAL ONCOLOGY Patel, M. I., Rhoads, K. F., Ma, Y., Ford, J. M., Visser, B. C., Kunz, P. L., Fisher, G. A., Chang, D. T., Koong, A., Norton, J. A., Poultsides, G. A. 2013; 20 (5): 1631-1638

    Abstract

    The gastric cancer AJCC/UICC staging system recently underwent significant revisions, but studies on Asian patients have reported a lack of adequate discrimination between various consecutive stages. We sought to validate the new system on a U.S. population database.California Cancer Registry data linked to the Office of Statewide Health Planning and Development discharge abstracts were used to identify patients with gastric adenocarcinoma (esophagogastric junction and gastric cardia tumors excluded) who underwent curative-intent surgical resection in California from 2002 to 2006. AJCC/UICC stage was recalculated based on the latest seventh edition. Overall survival probabilities were calculated using the Kaplan-Meier method.Of 1905 patients analyzed, 54 % were males with a median age of 70 years. Median number of pathologically examined lymph nodes was 12 (range, 1-90); 40 % of patients received adjuvant chemotherapy, and 31 % received adjuvant radiotherapy. The seventh edition AJCC/UICC system did not distinguish outcome adequately between stages IB and IIA (P = 0.40), or IIB and IIIA (P = 0.34). By merging stage II into 1 category and moving T2N1 to stage IB and T2N2, T1N3 to stage IIIA, we propose a new grouping system with improved discriminatory abilityIn this first study validating the new seventh edition AJCC/UICC staging system for gastric cancer on a U.S. population with a relatively limited number of lymph nodes examined, we found stages IB and IIA, as well as IIB and IIIA to perform similarly. We propose a revised stage grouping for the AJCC/UICC staging system that better discriminates between outcomes.

    View details for DOI 10.1245/s10434-012-2724-5

    View details for Web of Science ID 000317308200032

    View details for PubMedID 23149854

  • Complete resection of a rare intrahepatic variant of a choledochal cyst JOURNAL OF PEDIATRIC SURGERY Salles, A., Kastenberg, Z. J., Wall, J. K., Visser, B. C., Bruzoni, M. 2013; 48 (3): 652-654

    Abstract

    The vast majority of choledochal cysts occur as either saccular or diffuse fusiform dilatation of the extrahepatic bile duct. We describe the complete resection of a rare single intrahepatic choledochal cyst communicating with the extrahepatic biliary tree. While previous reports describe partial resection with enteral drainage, we performed a complete resection of this rare choledochal cyst.

    View details for DOI 10.1016/j.jpedsurg.2012.12.016

    View details for Web of Science ID 000316470100037

    View details for PubMedID 23480926

  • Hospital readmission after a pancreaticoduodenectomy: an emerging quality metric? HPB Kastenberg, Z. J., Morton, J. M., Visser, B. C., Norton, J. A., Poultsides, G. A. 2013; 15 (2): 142-148

    Abstract

    Hospital readmission has attracted attention from policymakers as a measure of quality and a target for cost reduction. The aim of the study was to evaluate the frequency and patterns of rehospitalization after a pancreaticoduodenectomy (PD).The records of all patients undergoing a PD at an academic medical centre for malignant or benign diagnoses between January 2006 and September 2011 were retrospectively reviewed. The incidence, aetiology and predictors of subsequent readmission(s) were analysed.Of 257 consecutive patients who underwent a PD, 50 (19.7%) were readmitted within 30 days from discharge. Both the presence of any post-operative complication (P = 0.049) and discharge to a nursing/rehabilitation facility or to home with health care services (P = 0.018) were associated with readmission. The most common reasons for readmission were diet intolerance (36.0%), pancreatic fistula/abscess (26.0%) and superficial wound infection (8.0%). Nine (18.0%) readmissions had lengths of stay of 2 days or less and in four of those (8.0%) diagnostic evaluation was eventually negative.Approximately one-fifth of patients require hospital readmission within 30 days of discharge after a PD. A small fraction of these readmissions are short (2 days or less) and may be preventable or manageable in the outpatient setting.

    View details for DOI 10.1111/j.1477-2574.2012.00563.x

    View details for Web of Science ID 000313548400009

    View details for PubMedID 23297725

  • The Epidemiology of Idiopathic Acute Pancreatitis, Analysis of the Nationwide Inpatient Sample From 1998 to 2007 PANCREAS Chen, Y., Zak, Y., Hernandez-Boussard, T., Park, W., Visser, B. C. 2013; 42 (1): 1-5

    Abstract

    The study aimed to better define the epidemiology of idiopathic acute pancreatitis (IAP).We identified admissions with primary diagnosis of acute pancreatitis (AP) in Nationwide Inpatient Sample between 1998 and 2007. Idiopathic AP was defined as all cases after excluding International Classification of Diseases, Ninth Revision, codes for other causes of AP (including biliary, alcoholic, trauma, iatrogenic, hyperparathyroidism, hyperlipidemia, etc).Among the primary admissions for AP, 26.9% had biliary pancreatitis, 25.1% alcoholic, and 36.5% idiopathic. Idiopathic AP had estimated 81,8025 admissions with a mean hospitalization of 5.6 days. Patients with IAP accounted for almost half of the fatalities among the cases of AP (48.2%) and had a higher mortality rate than both patients with biliary pancreatitis and patients with alcoholic pancreatitis (1.9%, 1.5%, and 1.0%, respectively, P < 0.01). Forty-six percent of patients with biliary pancreatitis underwent cholecystectomy during the index hospitalization, compared with 0.42% of patients with IAP. Patients with IAP had a demographic distribution similar to that of patients with biliary AP (female predominant and older), which was distinct from patients with alcoholic pancreatitis (male predominant and younger). There was a gradual but steady decrease in the incidence of IAP, from 41% in 1998 to 30% in 2007.Despite improving diagnostics, IAP remains a common clinical problem with a significant mortality. Standardization of the clinical management of these patients warrants further investigation.

    View details for DOI 10.1097/MPA.0b013e3182572d3a

    View details for Web of Science ID 000312560200001

    View details for PubMedID 22750972

  • Neoadjuvant Imatinib for Borderline Resectable GIST JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK Koontz, M. Z., Visser, B. M., Kunz, P. L. 2012; 10 (12): 1477-1482

    Abstract

    A 36-year-old woman presented to the emergency department with black stools and syncope. Her hemoglobin was 7.0 and her red blood cells were microcytic. Upper endoscopy did not identify a clear source of bleeding, but a bulge in the third portion of the duodenum was noted. A CT scan showed a large extraintestinal mass, and follow-up esophagogastroduodenoscopy/endoscopic ultrasound with biopsy revealed a spindle cell neoplasm, consistent with gastrointestinal stromal tumor (GIST). Because of the size of the lesion and association with the superior mesenteric vein and common bile duct, she was referred to medical oncology for consideration of neoadjuvant imatinib. Neoadjuvant tyrosine kinase inhibitor therapy for GISTs is emerging as a viable treatment strategy for borderline resectable tumors, although the dose, duration, and optimal imaging modalities have not been clearly established. Recent pathologic and radiographic data have provided insight into the mechanism and kinetics of this approach. This case report presents a patient for whom surgery was facilitated using neoadjuvant imatinib.

    View details for Web of Science ID 000312114200004

    View details for PubMedID 23221786

  • Changes in spleen volume after resection of hepatic colorectal metastases CLINICAL RADIOLOGY Jacobs, K. E., Visser, B. C., Gayer, G. 2012; 67 (10): 982-987

    Abstract

    To identify and describe changes in spleen volume occurring in patients with colorectal metastases to the liver after partial hepatectomy.Forty-one consecutive patients (20 men, 21 women) with histopathology-proven colorectal liver metastases who underwent partial hepatectomy between August 2007 and April 2011 were included. Liver and spleen volumes were measured by computed tomography (CT) volumetry on the most recent CT prior to surgery and on all CTs obtained within a year after partial hepatectomy. Patients were carefully evaluated for and excluded if they had co-morbid conditions known to cause splenomegaly or risk factors for portal hypertension such as underlying liver disease and portal vein thrombosis.Thirty-two (78%) patients demonstrated an increase in spleen volume on the first post-operative CT, with more than a double increase in volume amongst five patients. Spleen volume increased by an average of 43% within 3 months of partial hepatectomy (p < 0.0001) and remained increased through 6 months after surgery, returning to near baseline thereafter. In the remaining nine (22%) patients, the spleen was observed to decrease an average of 11% in volume on first postoperative CT (p < 0.005).Splenic enlargement after partial hepatectomy of colorectal metastases is a common finding on CT. Increased familiarity amongst radiologists of this phenomenon as likely reflecting physiological changes is important in order to avoid unnecessary evaluation for underlying conditions causing interval enlargement of the spleen.

    View details for DOI 10.1016/j.crad.2012.03.013

    View details for Web of Science ID 000309094900007

    View details for PubMedID 22608244

  • Lymph Nodes and Survival in Pancreatic Neuroendocrine Tumors ARCHIVES OF SURGERY Krampitz, G. W., Norton, J. A., Poultsides, G. A., Visser, B. C., Sun, L., Jensen, R. T. 2012; 147 (9): 820-827

    Abstract

    Lymph node metastases decrease survival in patients with pancreatic neuroendocrine tumors (pNETs).Prospective database searches.National Institutes of Health (NIH) and Stanford University Hospital (SUH).A total of 326 patients underwent surgical exploration for pNETs at the NIH (n = 216) and SUH (n = 110).Overall survival, disease-related survival, and time to development of liver metastases.Forty patients (12.3%) underwent enucleation and 305 (93.6%) underwent resection. Of the patients who underwent resection, 117 (35.9%) had partial pancreatectomy and 30 (9.2%) had a Whipple procedure. Forty-one patients also had liver resections, 21 had wedge resections, and 20 had lobectomies. Mean follow-up was 8.1 years (range, 0.3-28.6 years). The 10-year overall survival for patients with no metastases or lymph node metastases only was similar at 80%. As expected, patients with liver metastases had a significantly decreased 10-year survival of 30% (P < .001). The time to development of liver metastases was significantly reduced for patients with lymph node metastases alone compared with those with none (P < .001). For the NIH cohort with longer follow-up, disease-related survival was significantly different for those patients with no metastases, lymph node metastases alone, and liver metastases (P < .001). Extent of lymph node involvement in this subgroup showed that disease-related survival decreased as a function of the number of lymph nodes involved (P = .004).As expected, liver metastases decrease survival of patients with pNETs. Patients with lymph node metastases alone have a shorter time to the development of liver metastases that is dependent on the number of lymph nodes involved. With sufficient long-term follow-up, lymph node metastases decrease disease-related survival. Careful evaluation of number and extent of lymph node involvement is warranted in all surgical procedures for pNETs.

    View details for Web of Science ID 000308883700011

    View details for PubMedID 22987171

  • Preoperative embolization of replaced right hepatic artery prior to pancreaticoduodenectomy JOURNAL OF SURGICAL ONCOLOGY Cloyd, J. M., Chandra, V., Louie, J. D., Rao, S., Visser, B. C. 2012; 106 (4): 509-512

    Abstract

    Aberrancy of the hepatic arterial anatomy is common. Because of its course directly adjacent to the head of the pancreas, a replaced right hepatic artery (RHA) is vulnerable to invasion by peri-pancreatic malignancies. Division of the RHA at the time of pancreaticoduodenectomy, however, may result in hepatic infarction and/or bilioenteric anastomotic complications. We report two cases of patients undergoing preoperative embolization of tumor encased replaced RHAs to allow for sufficient collateralization prior to pancreaticoduodenectomy.

    View details for DOI 10.1002/jso.23082

    View details for Web of Science ID 000307550900026

    View details for PubMedID 22374866

  • Sump Syndrome as a Complication of Choledochoduodenostomy DIGESTIVE DISEASES AND SCIENCES Qadan, M., Clarke, S., Morrow, E., Triadafilopoulos, G., Visser, B. 2012; 57 (8): 2011-2015

    View details for DOI 10.1007/s10620-011-2020-4

    View details for Web of Science ID 000306930100007

    View details for PubMedID 22167692

  • Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes HPB Visser, B. C., Ma, Y., Zak, Y., Poultsides, G. A., Norton, J. A., Rhoads, K. F. 2012; 14 (8): 539-547

    Abstract

    There are little data available regarding compliance with the National Comprehensive Cancer Network (NCCN) guidelines. We investigated variation in the management of pancreatic cancer (PC) among large hospitals in California, USA, specifically to evaluate whether compliance with NCCN guidelines correlates with patient outcomes.The California Cancer Registry was used to identify patients treated for PC from 2001 to 2006. Only hospitals with ? 400 beds were included to limit evaluation to centres possessing resources to provide multimodality care (n= 50). Risk-adjusted multivariable models evaluated predictors of adherence to stage-specific NCCN guidelines for PC and mortality.In all, 3706 patients were treated for PC in large hospitals during the study period. Compliance with NCCN guidelines was only 34.5%. Patients were less likely to get recommended therapy with advanced age and low socioeconomic status (SES). Using multilevel analysis, controlling for patient factors (including demographics and comorbidities), hospital factors (e.g. size, academic affiliation and case volume), compliance with NCCN guidelines was associated with a reduced risk of mortality [odds ratio (OR) for death 0.64 (0.53-0.77, P < 0.0001)].There is relatively poor overall compliance with the NCCN PC guidelines in California's large hospitals. Higher compliance rates are correlated with improved survival. Compliance is an important potential measure of the quality of care.

    View details for DOI 10.1111/j.1477-2574.2012.00496.x

    View details for Web of Science ID 000305993800007

    View details for PubMedID 22762402

  • Pancreatic Neuroendocrine Tumors: Radiographic Calcifications Correlate with Grade and Metastasis ANNALS OF SURGICAL ONCOLOGY Poultsides, G. A., Huang, L. C., Chen, Y., Visser, B. C., Pai, R. K., Jeffrey, R. B., Park, W. G., Chen, A. M., Kunz, P. L., Fisher, G. A., Norton, J. A. 2012; 19 (7): 2295-2303

    Abstract

    Studies to identify preoperative prognostic variables for pancreatic neuroendocrine tumor (PNET) have been inconclusive. Specifically, the prevalence and prognostic significance of radiographic calcifications in these tumors remains unclear.From 1998 to 2009, a total of 110 patients with well-differentiated PNET underwent surgical resection at our institution. Synchronous liver metastases present in 31 patients (28%) were addressed surgically with curative intent. Patients with high-grade PNET were excluded. The presence of calcifications in the primary tumor on preoperative computed tomography was recorded and correlated with clinicopathologic variables and overall survival.Calcifications were present in 16% of patients and were more common in gastrinomas and glucagonomas (50%), but never encountered in insulinomas. Calcified tumors were larger (median size 4.5 vs. 2.3 cm, P=0.04) and more commonly associated with lymph node metastasis (75 vs. 35%, P=0.01), synchronous liver metastasis (62 vs. 21%, P<0.01), and intermediate tumor grade (80 vs. 31%, P<0.01). On multivariate analysis of factors available preoperatively, calcifications (P=0.01) and size (P<0.01) remained independent predictors of lymph node metastasis. Overall survival after resection was significantly worse in the presence of synchronous liver metastasis (5-year, 64 vs. 86%, P=0.04), but not in the presence of radiographic calcifications.Calcifications on preoperative computed tomography correlate with intermediate grade and lymph node metastasis in well-differentiated PNET. This information is available preoperatively and supports the routine dissection of regional lymph nodes through formal pancreatectomy rather than enucleation in calcified PNET.

    View details for DOI 10.1245/s10434-012-2305-7

    View details for Web of Science ID 000305558000030

    View details for PubMedID 22396008

  • Abdominal Mass, Anemia, Diabetes Mellitus, and Necrolytic Migratory Erythema DIGESTIVE DISEASES AND SCIENCES Qadan, M., Visser, B., Kim, J., Pai, R., Triadafilopoulos, G. 2012; 57 (6): 1465-1468

    View details for DOI 10.1007/s10620-011-1967-5

    View details for Web of Science ID 000304396700007

    View details for PubMedID 22089253

  • Video-assisted thoracoscopic transdiaphragmatic liver resection for hepatocellular carcinoma SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Cloyd, J. M., Visser, B. C. 2012; 26 (6): 1772-1776

    Abstract

    Because of technical complexity, concern for vascular control, and uncertainty in regard to oncologic outcome, the application of minimally invasive techniques to liver surgery has been slower than in most other abdominal procedures. This is despite well-known advantages with respect to postoperative pain, length of hospitalization, and recovery time. Although laparoscopic liver surgery has recently become more common, the majority of laparoscopic liver resections comprise anterolateral wedge resections and left lateral sectorectomies. Laparoscopic resections of the posterosuperior segments are more difficult and few reports are available in the literature. Compared to laparoscopy, gaining access to tumors in the dome of the liver may be more easily obtained via thoracoscopy, thereby preserving the benefits of minimally invasive surgery. This technical report describes two cases of hepatocellular carcinoma in segments VII and VIII resected via a video-assisted thoracoscopic transdiaphragmatic approach.

    View details for DOI 10.1007/s00464-011-2062-x

    View details for Web of Science ID 000304161500042

    View details for PubMedID 22179452

  • Diagnostic accuracy of cyst fluid amphiregulin in pancreatic cysts BMC GASTROENTEROLOGY Tun, M. T., Pai, R. K., Kwok, S., Dong, A., Gupta, A., Visser, B. C., Norton, J. A., Poultsides, G. A., Banerjee, S., Van Dam, J., Chen, A. M., Friedland, S., Scott, B. A., Verma, R., Lowe, A. W., Park, W. G. 2012; 12

    Abstract

    Accurate tests to diagnose adenocarcinoma and high-grade dysplasia among mucinous pancreatic cysts are clinically needed. This study evaluated the diagnostic utility of amphiregulin (AREG) as a pancreatic cyst fluid biomarker to differentiate non-mucinous, benign mucinous, and malignant mucinous cysts.A single-center retrospective study to evaluate AREG levels in pancreatic cyst fluid by ELISA from 33 patients with a histological gold standard was performed.Among the cyst fluid samples, the median (IQR) AREG levels for non-mucinous (n = 6), benign mucinous (n = 15), and cancerous cysts (n = 15) were 85 pg/ml (47-168), 63 pg/ml (30-847), and 986 pg/ml (417-3160), respectively. A significant difference between benign mucinous and malignant mucinous cysts was observed (p = 0.025). AREG levels greater than 300 pg/ml possessed a diagnostic accuracy for cancer or high-grade dysplasia of 78% (sensitivity 83%, specificity 73%).Cyst fluid AREG levels are significantly higher in cancerous and high-grade dysplastic cysts compared to benign mucinous cysts. Thus AREG exhibits potential clinical utility in the evaluation of pancreatic cysts.

    View details for DOI 10.1186/1471-230X-12-15

    View details for Web of Science ID 000301923400002

    View details for PubMedID 22333441

  • Adult Intestinal Malrotation: When Things Turn the Wrong Way DIGESTIVE DISEASES AND SCIENCES Palmer, O. P., Rhee, H. H., Park, W. G., Visser, B. C. 2012; 57 (2): 284-287

    View details for DOI 10.1007/s10620-011-1818-4

    View details for Web of Science ID 000299487500005

    View details for PubMedID 21805171

  • Single-cell dissection of transcriptional heterogeneity in human colon tumors NATURE BIOTECHNOLOGY Dalerba, P., Kalisky, T., Sahoo, D., Rajendran, P. S., Rothenberg, M. E., Leyrat, A. A., Sim, S., Okamoto, J., Johnston, D. M., Qian, D., Zabala, M., Bueno, J., Neff, N. F., Wang, J., Shelton, A. A., Visser, B., Hisamori, S., Shimono, Y., Van De Wetering, M., Clevers, H., Clarke, M. F., Quake, S. R. 2011; 29 (12): 1120-U11

    Abstract

    Cancer is often viewed as a caricature of normal developmental processes, but the extent to which its cellular heterogeneity truly recapitulates multilineage differentiation processes of normal tissues remains unknown. Here we implement single-cell PCR gene-expression analysis to dissect the cellular composition of primary human normal colon and colon cancer epithelia. We show that human colon cancer tissues contain distinct cell populations whose transcriptional identities mirror those of the different cellular lineages of normal colon. By creating monoclonal tumor xenografts from injection of a single (n = 1) cell, we demonstrate that the transcriptional diversity of cancer tissues is largely explained by in vivo multilineage differentiation and not only by clonal genetic heterogeneity. Finally, we show that the different gene-expression programs linked to multilineage differentiation are strongly associated with patient survival. We develop two-gene classifier systems (KRT20 versus CA1, MS4A12, CD177, SLC26A3) that predict clinical outcomes with hazard ratios superior to those of pathological grade and comparable to those of microarray-derived multigene expression signatures.

    View details for DOI 10.1038/nbt.2038

    View details for Web of Science ID 000298038700023

    View details for PubMedID 22081019

  • Ruptured Biliary Cystadenoma Managed by Angiographic Embolization and Interval Partial Hepatectomy DIGESTIVE DISEASES AND SCIENCES Ghole, S. A., Bakhtary, S., Staudenmayer, K., Sze, D. Y., Pai, R. K., Visser, B. C., Norton, J. A., Poultsides, G. A. 2011; 56 (7): 1949-1953

    View details for DOI 10.1007/s10620-011-1677-z

    View details for Web of Science ID 000291481800006

    View details for PubMedID 21445579

  • Predictors of Surgical Intervention for Hepatocellular Carcinoma ARCHIVES OF SURGERY Zak, Y., Rhoads, K. F., Visser, B. C. 2011; 146 (7): 778-784

    Abstract

    To define current use of surgical therapies for hepatocellular carcinoma (HCC) and evaluate the correlation of various patient and hospital characteristics with the receipt of these interventions.Retrospective cohort.California Cancer Registry data linked to the Office of Statewide Health Planning and Development patient discharge abstracts between 1996 and 2006.Patients with primary HCC.Receipt of liver transplant, hepatic resection, or local ablation.Of 12,148 HCC cases, 2390 (20%) underwent surgical intervention. Three hundred eleven (2.56%) received a liver transplant, 1307 (10.8%) underwent resection, and 772 (6.35%) had local ablation. There were wide variations in treatment by race and hospital type. African American and Hispanic patients were less likely than white patients to undergo transplant (P < .05). African American and Hispanic patients were less likely than white and Asian/Pacific Islander patients to have hepatectomy or ablation (P < .05). In multivariable analysis, the apparent differences in surgical intervention by race/ethnicity were decreased when adjusting for the patients' socioeconomic and insurance statuses. Patients with lower socioeconomic status and no private insurance were less likely to receive any surgery (P < .01). Hospital characteristics also explained some variations. Disproportionate Share Hospitals and public, rural, and nonteaching hospitals were less likely to offer surgical treatment (P < .01).There are significant racial, socioeconomic, and hospital-type disparities in surgical treatment of HCC.

    View details for DOI 10.1001/archsurg.2011.37

    View details for Web of Science ID 000292877800002

    View details for PubMedID 21422327

  • Pancreatic Endocrine Tumors With Major Vascular Abutment, Involvement, or Encasement and Indication for Resection ARCHIVES OF SURGERY Norton, J. A., Harris, E. J., Chen, Y., Visser, B. C., Poultsides, G. A., Kunz, P. C., Fisher, G. A., Jensen, R. T. 2011; 146 (6): 724-732

    Abstract

    Surgery for pancreatic endocrine tumors (PETs) with blood vessel involvement is controversial.Resection of PETs with major blood vessel involvement can be beneficial.The combined databases of the National Institutes of Health and Stanford University hospitals were queried.Operation, pathologic condition, complications, and disease-free and overall survival.Of 273 patients with PETs, 46 (17%) had preoperative computed tomography evidence of major vascular involvement. The mean size for the primary PET was 5.0 cm. The involved major vessel was as follows: portal vein (n = 20), superior mesenteric vein or superior mesenteric artery (n = 16), inferior vena cava (n = 4), splenic vein (n = 4), and heart (n = 2). Forty-two of 46 patients had a PET removed: 12 (27%) primary only, 30 (68%) with lymph nodes, and 18 (41%) with liver metastases. PETs were removed by either enucleation (n = 7) or resection (n = 35). Resections included distal or subtotal pancreatectomy in 23, Whipple in 10, and total in 2. Eighteen patients had concomitant liver resection: 10 wedge resection and 8 anatomic resections. Nine patients had vascular reconstruction: each had reconstruction of the superior mesenteric vein and portal vein, and 1 had concomitant reconstruction of the superior mesenteric artery. There were no deaths, but 12 patients had complications. Eighteen patients (41%) were immediately disease free, and 5 recurred with follow-up, leaving 13 (30%) disease-free long term. The 10-year overall survival was 60%. Functional tumors were associated with a better overall survival (P < .001), and liver metastases decreased overall survival (P < .001).These findings suggest that surgical resection of PETs with vascular abutment/invasion and nodal or distant metastases is indicated.

    View details for Web of Science ID 000291851500018

    View details for PubMedID 21690450

  • A NOVEL PRKAR1A MUTATION ASSOCIATED WITH PRIMARY PIGMENTED NODULAR ADRENOCORTICAL DISEASE AND THE CARNEY COMPLEX ENDOCRINE PRACTICE Peck, M. C., Visser, B. C., Norton, J. A., Pasche, L., Katznelson, L. 2010; 16 (2): 198-204

    Abstract

    To delineate the genetic and phenotypic features of Carney complex in a family with multiple cases of primary pigmented nodular adrenocortical disease (PPNAD).Detailed clinical, laboratory, genetic, radiologic, and pathologic findings are presented, and the pertinent literature is reviewed.A 17-year-old girl presented with symptoms and physical findings suggestive of hypercortisolemia, in addition to facial lentigines. She was found to have adrenocorticotropic hormone (ACTH)-independent Cushing syndrome. The adrenal glands appeared normal on computed tomographic scanning. Bilateral surgical adrenalectomy revealed PPNAD. Evaluation of her 14-year-old sister revealed ACTH-independent Cushing syndrome as well as facial lentigines, and adrenalectomy revealed PPNAD as well. Genetic testing of the 2 sisters and their mother (who also had multiple facial lentigines but did not have Cushing syndrome) revealed a novel mutation in the PRKAR1A gene.We describe a novel mutation in the PRKAR1A gene in a family with Carney complex and multiple members with PPNAD. PPNAD should be suspected in cases of ACTH-independent Cushing syndrome, and screening for Carney complex and its complications is recommended in all cases of PPNAD, including first-degree relatives.

    View details for DOI 10.4158/EP09245.OR

    View details for Web of Science ID 000277497400011

    View details for PubMedID 19833579

  • Development of a transillumination infrared modality for differential vasoactive optical imaging APPLIED OPTICS Dixit, S. S., Kim, H., Visser, B., Faris, G. W. 2009; 48 (10): D178-D186

    Abstract

    We present the development and implementation of a new near infrared transillumination imaging modality for tissue imaging. Exogenous inhaled hyperoxic and hypercarbic gases are used as "vasoactive contrast agents" via the production of changes in concentration of the endogenous HbO(2) and Hb in blood. This vasoactive differential imaging method is employed to acquire data and for subsequent image analysis. Spectroscopic changes obtained from transillumination measurements on the palms of healthy volunteers demonstrate the functionality of the imaging platform. This modality is being developed to monitor suspect breast lesions in a clinical setting based on the hypothesis that the atypical tumor vascular environment will yield sufficient contrast for differential optical imaging between diseased and healthy tissue.

    View details for Web of Science ID 000265443700022

    View details for PubMedID 19340107

  • Diagnostic evaluation of cystic pancreatic lesions HPB Visser, B. C., Muthusamy, V. R., Yeh, B. M., Coakley, F. V., Way, L. W. 2008; 10 (1): 63-69

    Abstract

    Cystic pancreatic neoplasms (CPNs) present a unique challenge in preoperative diagnosis. We investigated the accuracy of diagnostic methods for CPN.This retrospective cases series includes 70 patients who underwent surgery at a university hospital for presumed CPNs between 1997 and 2003, and for whom a definitive diagnosis was established. Variables examined included symptoms, preoperative work-up (including endoscopic retrograde cholangiopancreatography (ERCP) in 22 cases and endoscopic ultrasound (EUS) in 12), and operative and pathological findings. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) scans (n=50 patients; CT=48; MRI=13) were independently reviewed by two blinded GI radiologists.The final histopathologic diagnoses were mucinous cystic neoplasm (n=13), mucinous cystadenocarcinoma (10), serous cystadenoma (11), IPMN (14), simple cyst (3), cystic neuroendocrine tumor (5), pseudocyst (4), and other (10). Overall, 25 of 70 were malignant (37%), 21 premalignant (30%), and 24 benign (34%). The attending surgeon's preoperative diagnosis was correct in 31% of cases, incorrect in 29%, non-specific "cystic tumor" in 27%, and "pseudocyst vs. neoplasm" in 11%. Eight had been previously managed as pseudocysts, and 3 pseudocysts were excised as presumed CPN. In review of the CT and MRI, a multivariate analysis of the morphologic features did not identify predictors of specific pathologic diagnoses. Both radiologists were accurate with their preferred (no. 1) diagnosis in <50% of cases. MRI demonstrated no additional utility beyond CT.The diagnosis of CPN remains challenging. Cross-sectional imaging methods do not reliably give an accurate preoperative diagnosis. Surgeons should continue to err on the side of resection.

    View details for DOI 10.1080/13651820701883155

    View details for Web of Science ID 000207813300012

    View details for PubMedID 18695762

  • Open cholecystectomy in the laparoendoscopic era AMERICAN JOURNAL OF SURGERY Visser, B. C., Parks, R. W., Garden, O. J. 2008; 195 (1): 108-114

    Abstract

    Laparoscopic cholecystectomy has all but replaced the traditional open approach. Hence open cholecystectomy (OC) is principally reserved for cases in which laparoscopy fails, leaving fewer surgeons with experience in the procedure required for the most challenging cases. This review of OC includes discussion of the indications for a primary open approach, conversion from laparoscopy, technical aspects of OC, and alternatives (cholecystostomy and subtotal cholecystectomy). Strategies for safe OC must be formally addressed in residency programs.

    View details for DOI 10.1016/j.amjsurg.2007.04.008

    View details for Web of Science ID 000251968300022

    View details for PubMedID 18082551

  • Characterization of cystic pancreatic masses: Relative accuracy of CT and MRI AMERICAN JOURNAL OF ROENTGENOLOGY Visser, B. C., Yeh, B. M., Qayyum, A., Way, L. W., McCulloch, C. E., Coakley, F. V. 2007; 189 (3): 648-656

    Abstract

    The objective of our study was to determine the role and relative accuracy of CT and MRI in the characterization of cystic pancreatic masses.We retrospectively identified 58 patients with histopathologically proven cystic pancreatic masses at our institution who underwent preoperative CT (n = 40), MRI (n = 6), or both (n = 12). Two radiologists independently recorded their leading diagnoses with levels of diagnostic certainty (0-100%), their estimates of overall likelihood of malignancy (0-100%), and the morphologic characteristics of the tumors. Data were analyzed to determine relative accuracy in the diagnosis of malignancy, relationship between diagnostic certainty and accuracy, and frequency of malignancy in unilocular thin-walled cysts smaller than 4 cm.Twenty-one (36%) of 58 masses were malignant. CT and MRI were equally accurate in establishing the diagnosis of malignancy (area under the receiver operating characteristic curve [A(z)] = 0.91 and 0.85 for reviewers 1 and 2 at MRI vs 0.82 and 0.76 at CT, respectively; p > 0.05). The leading diagnosis given by reviewers 1 and 2 was correct in 46% (32/70) and 43% (30/70) of the studies, respectively. When reviewer diagnostic certainty was 90% or more, the corresponding values were not significantly (p > 0.05) improved at 55% (12/22) and 48% (10/21), respectively. Two (15%) of 13 unilocular thin-walled cysts smaller than 4 cm were frankly malignant.CT and MRI are reasonably and similarly accurate in the characterization of cystic pancreatic masses as benign or malignant; limitations include a substantial rate of misdiagnosis even when reviewer certainty is high and a moderate frequency of malignancy in small morphologically benign-appearing cysts.

    View details for DOI 10.2214/AJR.07.2365

    View details for Web of Science ID 000249038000026

    View details for PubMedID 17715113

  • The influence of portoenterostomy on transplantation for biliary atresia LIVER TRANSPLANTATION Visser, B. C., Suh, I., Hirose, S., Rosenthal, P., LEE, H., Roberts, J. P., Hirose, R. 2004; 10 (10): 1279-1286

    Abstract

    After portoenterostomy (PE) for biliary atresia (BA), many patients suffer progressive deterioration of liver function and ultimately require liver transplantation. We retrospectively reviewed a single center's experience with pediatric liver transplantation for BA from 1988 to 2002. Sixty-six patients underwent 69 liver transplants for BA. Forty-two (63%) patients had previously undergone Kasai PE, 11 (17%) biliary appendicoduodenostomy (BAD), and 13 (20%) had no prior biliary drainage (NBD). The BAD procedure offered only short-term biliary drainage--the mean interval between PE and transplant was more than twice that for Kasai patients than for BAD patients (132 versus 49 weeks). The transplants included 11 cadaveric partial, 27 cadaveric whole, and 31 living related transplants. Three patients required retransplant. Prior PE did not increase the incidence of major perioperative complications or unplanned reexploration. After transplant, the 1-, 5-, and 10-year actuarial graft survival rates were 87%, 86%, and 80%, respectively. The 1-, 5-, and 10-year actuarial patient survival rates were 91%, 89%, and 83%. PE remains an important bridge to transplant. In conclusion, transplantation for BA offers excellent long-term graft and patient survival.

    View details for DOI 10.1002/lt.20234

    View details for Web of Science ID 000224109300010

    View details for PubMedID 15376306

  • Congenital choledochal cysts in adults ARCHIVES OF SURGERY Visser, B. C., Suh, I., Way, L. W., Kang, S. M. 2004; 139 (8): 855-860

    Abstract

    Excision of the extrahepatic portion of congenital choledochal cysts (CCs) avoids the risk of cancer. The standard classification scheme is out of date.Retrospective case series and literature review.Tertiary care university hospital.Thirty-eight adult patients diagnosed as having CC from 1990 to 2004.Clinical and radiographic imaging findings, operative treatment, pathologic features, and clinical outcome.Thirty-nine adult patients were treated for CCs (mean [SD] age at diagnosis, 31 [17] years, and mean [SD] age at surgery 37 [14] years). The primary report was abdominal pain (36 of 39 patients). Eight patients had cholangitis, 5 had jaundice, and 6 had pancreatitis. Radiographic imaging studies and operative findings showed that the abnormality predominantly involved the extrahepatic bile duct in 30 patients, the intrahepatic and extrahepatic bile ducts in 7 patients; and 2 were diverticula attached to the common bile duct. Surgical treatment in 29 (90%) of 31 patients with benign cysts (regardless of intrahepatic changes) consisted of resection of the enlarged extrahepatic bile duct and gallbladder and Roux-en-Y hepaticojejunostomy. Eight patients (21%) were initially seen with associated cancer (cholangiocarcinoma of the extrahepatic duct in 6; gallbladder cancer in 2). Seven of 8 patients had a prior diagnosis of CC but had undergone a drainage operation (3 patients), expectant treatment (3 patients), or incomplete excision (1patient). In none of the patients with cancer was surgery not curative. Nine patients had previously undergone a cystoduodenostomy and/or cystojejunostomy as children. Four of them had cancer on presentation as adults. There were no postoperative deaths. Cancer subsequently developed in no patient whose benign extrahepatic cyst was excised, regardless of the extent of enlargement of the intrahepatic bile duct.Congenital CCs consist principally of congenital dilation of the extrahepatic bile duct with a variable amount of intrahepatic involvement. We believe that the standard classification scheme is confusing, unsupported by evidence, misleading, and serves no purpose. The distinction between type I and type IV CCs has to be arbitrary, for the intrahepatic ducts were never completely normal. Although Caroli disease may resemble CCs morphologically, with respect to cause and clinical course, the 2 are unrelated. The other rare anomalies (gallbladderlike diverticula; choledochocele) are also unrelated to CC. Therefore, the term "congential choledochal cyst" should be exclusively reserved for congenital dilation of the extrahepatic and intrahepatic bile ducts apart from Caroli disease, and the other conditions should be referred to by their names, for example, choledochocele, and should no longer be thought of as subtypes of CC. Our data demonstrate once again a persistent tendency to recommend expectant treatment in patients without symptoms and the extreme risk of nonexcisional treatment. The entire extrahepatic biliary tree should be removed when CC is diagnosed whether or not symptoms are present. The outcome of that approach was excellent.

    View details for Web of Science ID 000223118400014

    View details for PubMedID 15302695

  • Diagnostic imaging of cystic pancreatic neoplasms SURGICAL ONCOLOGY-OXFORD Visser, B. C., Muthusamay, V. R., Mulvihill, S. J., Coakley, F. 2004; 13 (1): 27-39

    Abstract

    Cystic pancreatic neoplasms are being diagnosed with growing frequency due to improving imaging technologies and increasing clinician awareness. Distinguishing cystic neoplasms from pseudocysts and discriminating among the various cystic neoplasms is essential to appropriate management. The backbone of diagnosis of these tumors continues to be cross-sectional imaging by CT and MRI. Despite refinements in technology and significant progress in characterizing these lesions, the overall accuracy of CT and MR is limited. EUS, especially as means of FNA, will have an increasing role in the evaluation of selected cases as experience grows. No radiologic investigation can reliably distinguish cystic neoplasms from pseudocysts nor differentiate among cystic neoplasms in all cases. For uncertain lesions, surgeons should favor either careful observation with serial imaging or surgical resection.

    View details for DOI 10.1016/j.suronc.2004.01.002

    View details for Web of Science ID 000221771200004

    View details for PubMedID 15145031

  • Adjuvant and neoadjuvant therapy for esophageal cancer: a critical reappraisal SURGICAL ONCOLOGY-OXFORD Visser, B. C., Venook, A. P., Patti, M. G. 2003; 12 (1): 1-7

    Abstract

    Despite important refinements of surgical technique and significant progress in perioperative care, esophageal cancer remains highly lethal. Therefore, hope for improvement in the prognosis of esophageal cancer lies largely in the use of additional therapy. Promising data from numerous Phase II trials and a single Phase III trial led to the widespread adoption of neoadjuvant chemoradiotherapy. However, subsequent randomized trials did not conclusively demonstrate a survival benefit with any of the current neoadjuvant protocols for patients with resectable esophageal cancer. Benefit, if any, exists only for complete pathologic responders. Neoadjuvant chemoradiation should not be used in patients with resectable esophageal cancer outside of the clinical trials. Future investigation must focus on the development of new biologic or chemotherapeutic agents, and the identification of biologic markers that might predict response to chemoradiation.

    View details for DOI 10.1016/S0960-7404(02)00072-5

    View details for Web of Science ID 000182503800001

    View details for PubMedID 12689665

  • Safety and timing of nonobstetric abdominal surgery in pregnancy DIGESTIVE SURGERY Visser, B. C., Glasgow, R. E., Mulvihill, K. K., Mulvihill, S. J. 2001; 18 (5): 409-417

    Abstract

    Abdominal disorders occurring during pregnancy pose special difficulties in diagnosis and management to the obstetrician and surgeon. The advisability of nonobstetric abdominal surgery during pregnancy is uncertain. Our objective was to evaluate the safety and timing of abdominal surgery during pregnancy.We retrospectively reviewed 77 consecutive gravid patients undergoing nonobstetric abdominal surgery from 1989 to 1996 at an urban academic medical center and a large affiliated community teaching hospital. Medical records were evaluated for clinical presentation, perioperative management, preterm labor, and maternal and fetal morbidity and mortality.The rate of nonobstetric abdominal surgery during pregnancy was 1 in every 527 births. Among the 77 patients, the indications for surgery were adnexal mass (42%), acute appendicitis (21%), gallstone disease (17%) and other (21%). There was no maternal or fetal loss or identifiable neonatal birth defect. Preterm labor occurred in 26% of the second-trimester patients and 82% of the third-trimester patients. Preterm labor was most common in patients with appendicitis and after adnexal surgery. Preterm delivery occurred in 16% of the patients, but appeared to be directly related to the abdominal surgery in only 5%.Surgery during the first or second trimester is not associated with significant preterm labor, fetal loss or risk of teratogenicity. Surgery during the third trimester is associated with preterm labor, but not fetal loss.

    View details for Web of Science ID 000172650500013

    View details for PubMedID 11721118

Conference Proceedings


  • Intensity-Modulated Radiotherapy for Pancreatic Adenocarcinoma Abelson, J. A., Murphy, J. D., Minn, A. Y., Chung, M., Fisher, G. A., Ford, J. M., Kunz, P., Norton, J. A., Visser, B. C., Poultsides, G. A., Koong, A. C., Chang, D. T. ELSEVIER SCIENCE INC. 2012: E595-E601

    Abstract

    To report the outcomes and toxicities in patients treated with intensity-modulated radiotherapy (IMRT) for pancreatic adenocarcinoma.Forty-seven patients with pancreatic adenocarcinoma were treated with IMRT between 2003 and 2008. Of these 47 patients, 29 were treated adjuvantly and 18 definitively. All received concurrent 5-fluorouracil chemotherapy. The treatment plans were optimized such that 95% of the planning target volume received the prescription dose. The median delivered dose for the adjuvant and definitive patients was 50.4 and 54.0 Gy, respectively.The median age at diagnosis was 63.9 years. For adjuvant patients, the 1- and 2-year overall survival rate was 79% and 40%, respectively. The 1- and 2-year recurrence-free survival rate was 58% and 17%, respectively. The local-regional control rate at 1 and 2 years was 92% and 80%, respectively. For definitive patients, the 1-year overall survival, recurrence-free survival, and local-regional control rate was 24%, 16%, and 64%, respectively. Four patients developed Grade 3 or greater acute toxicity (9%) and four developed Grade 3 late toxicity (9%).Survival for patients with pancreatic cancer remains poor. A small percentage of adjuvant patients have durable disease control, and with improved therapies, this proportion will increase. Systemic therapy offers the greatest opportunity. The present results have demonstrated that IMRT is well tolerated. Compared with those who received three-dimensional conformal radiotherapy in previously reported prospective clinical trials, patients with pancreatic adenocarcinoma treated with IMRT in our series had improved acute toxicity.

    View details for DOI 10.1016/j.ijrobp.2011.09.035

    View details for Web of Science ID 000300980300003

    View details for PubMedID 22197234

  • Expression of p16(INK4A) But Not Hypoxia Markers or Poly Adenosine Diphosphate-Ribose Polymerase Is Associated With Improved Survival in Patients With Pancreatic Adenocarcinoma Chang, D. T., Chapman, C. H., Norton, J. A., Visser, B., Fisher, G. A., Kunz, P., Ford, J. M., Koong, A. C., Pai, R. K. WILEY-BLACKWELL. 2010: 5179-5187

    Abstract

    Pancreatic cancer is associated with mutations in the tumor suppressor gene cyclin-dependent kinase inhibitor 2A (p16(INK4A) ), a regulator of the cell cycle and apoptosis. This study investigates whether immunohistochemical expression of p16(INK4A) as well as hypoxia markers and poly adenosine diphosphate-ribose polymerase (PARP) correlates with survival in patients with resected pancreatic adenocarcinoma.Seventy-three patients with pancreatic adenocarcinoma who underwent curative resection at Stanford University were included. From the surgical specimens, a tissue microarray was constructed using triplicate tissue cores from the primary tumor and used for immunohistochemical staining for the following markers: carbonic anhydrase IX, dihydrofolate reductase, p16(INK4A) , and PARP1/2. Staining was scored as either positive or negative and percentage positive staining. Staining score was correlated with overall survival (OS) and progression-free survival (PFS).Of the markers tested, only immunohistochemical expression of p16(INK4A) correlated with clinical outcome. On univariate analysis, p16(INK4A) expression in the tumor was associated with improved OS (P = .038) but not PFS (P = .28). The median survival for patients with positive versus negative p16(INK4A) staining was 28.8 months versus 18 months. On multivariate analysis, p16(INK4A) expression was associated with improved OS (P = .026) but not PFS (P = .25). Age (P = .0019) and number of nodes involved (P = .025) were also significant for OS. Adjuvant chemotherapy and margin status did not correlate with OS or PFS.Expression of p16(INK4A) is associated with improved OS in patients with resected pancreatic adenocarcinoma. Further investigation is needed for validation, given conflicting data in the published literature. .

    View details for DOI 10.1002/cncr.25481

    View details for Web of Science ID 000284047400009

    View details for PubMedID 20665497

  • Comparison of Intensity-Modulated Radiotherapy and 3-Dimensional Conformal Radiotherapy as Adjuvant Therapy for Gastric Cancer Minn, A. Y., Hsu, A., La, T., Kunz, P., Fisher, G. A., Ford, J. M., Norton, J. A., Visser, B., Goodman, K. A., Koong, A. C., Chang, D. T. JOHN WILEY & SONS INC. 2010: 3943-3952

    Abstract

    The current study was performed to compare the clinical outcomes and toxicity in patients treated with postoperative chemoradiotherapy for gastric cancer using intensity-modulated radiotherapy (IMRT) versus 3-dimensional conformal radiotherapy (3D CRT).Fifty-seven patients with gastric or gastroesophageal junction cancer were treated postoperatively: 26 with 3D CRT and 31 with IMRT. Concurrent chemotherapy was capecitabine (n=31), 5-fluorouracil (5-FU) (n=25), or none (n=1). The median radiation dose was 45 Gy. Dose volume histogram parameters for kidney and liver were compared between treatment groups.The 2-year overall survival rates for 3D CRT versus IMRT were 51% and 65%, respectively (P=.5). Four locoregional failures occurred each in the 3D CRT (15%) and the IMRT (13%) patients. Grade>or=2 acute gastrointestinal toxicity was found to be similar between the 3D CRT and IMRT patients (61.5% vs 61.2%, respectively) but more treatment breaks were needed (3 vs 0, respectively). The median serum creatinine from before radiotherapy to most recent creatinine was unchanged in the IMRT group (0.80 mg/dL) but increased in the 3D CRT group from 0.80 mg/dL to 1.0 mg/dL (P=.02). The median kidney mean dose was higher in the IMRT versus the 3D CRT group (13.9 Gy vs 11.1 Gy; P=.05). The median kidney V20 was lower for the IMRT versus the 3D CRT group (17.5% vs 22%; P=.17). The median liver mean dose for IMRT and 3D CRT was 13.6 Gy and 18.6 Gy, respectively (P=.19). The median liver V30 was 16.1% and 28%, respectively (P<.001).Adjuvant chemoradiotherapy was well tolerated. IMRT was found to provide sparing to the liver and possibly renal function.

    View details for DOI 10.1002/cncr.25246

    View details for Web of Science ID 000280677100025

    View details for PubMedID 20564136

  • Death After Colectomy It's Later Than We Think Visser, B. C., Keegan, H., Martin, M., Wren, S. M. AMER MEDICAL ASSOC. 2009: 1021-1027

    Abstract

    Clinical outcomes are increasingly subject to objective assessment and professional accountability. Informed consent relies on accurate estimation of operative risk. Current scoring systems for assessment of operative mortality after colorectal surgery (CRS) almost uniformly report 30-day mortality and may not represent true risk.Prospective cohort.University-affiliated Veterans Affairs Medical Center.All patients who underwent resections of the colon and/or rectum (as the principal operation) at a single hospital whose data are captured in the Veterans Affairs National Surgical Quality Improvement Program (VA-NSQIP) database from January 1, 2000, through December 31, 2006.Mortality at 30 days and 90 days.The VA-NSQIP cohort included 186 patients who underwent CRS, including 148 patients who underwent elective procedures (79.6%) and 38 patients who underwent emergency procedures (20.4%). All but 8 patients were men, with a median age of 67 years (range, 26-92 years). Laparoscopic operations comprised 24.2% and open operations comprised 75.8%. Most (60.8%) were performed for neoplasms. The actual 30-day mortality rates (all, elective, and emergency procedures) were 4.3%, 1.4%, and 15.8%, respectively. These rates closely mirrored the calculated VA-NSQIP risk-adjusted observed-to-expected ratio for 30-day mortality (4.8%, 1.8%, and 18.2%, respectively). However, mortality at 90 days increased substantially to 9.1%, 4.1%, and 28.9%, respectively.The 30-day mortality significantly underreports the true risk of death after CRS. The 90-day mortality rate should be included as a standard outcome measure after CRS because it serves as a better estimation of risk for counseling patients.

    View details for Web of Science ID 000271890500009

    View details for PubMedID 19917938

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