Bio

Bio


Dr. Lee is a native of New York City. He attended the Sophie Davis School of Biomedical Education at the City College of New York and received his medical degree from New York Medical College. He completed general surgery residency training at Lenox Hill Hospital and fellowship training in surgical oncology at the City of Hope National Cancer Center. Dr. Lee led the Peritoneal Surface Malignancy Program at City of Hope prior to joining Stanford in 2019.

Dr. Lee is a surgical oncologist who specializes in the treatment of gastrointestinal malignancies. He has dedicated his clinical practice to the surgical management of metastatic disease, particularly to the liver and peritoneum. He has expertise in delivering regional cancer therapies such as heated intraperitoneal chemotherapy (HIPEC). Additionally, he performs surgery for cancers of the stomach, liver, pancreas, small intestine, colon, and soft tissue sarcoma. He utilizes minimally invasive and robotic surgical techniques when appropriate.

Dr. Lee leads the Regional Cancer Therapies program at Stanford. The program implements and develops novel treatment strategies for patients affected with peritoneal malignancies and oligometastatic disease to the liver. His research focus is on clinical outcomes of multidisciplinary management for gastric, hepatobiliary, and peritoneal surface malignancies. He is a member of a national consensus group performing collaborative research and developing clinical trials for HIPEC surgeries.

Clinical Focus


  • Surgical Oncology
  • HIPEC
  • Appendiceal Cancer
  • Peritoneal Surface Malignancies
  • Pancreatic Cancer
  • Biliary Tract Cancer
  • Stomach Cancer
  • Sarcoma
  • Neuroendocrine Tumors
  • Peritoneal Mesothelioma
  • General Surgery

Academic Appointments


Administrative Appointments


  • Director, Regional Cancer Therapies, Stanford University (2019 - Present)

Honors & Awards


  • Top Doctors, Los Angeles Magazine (2017-2019)

Professional Education


  • Medical Education: New York Medical College Registrar (2000) NY
  • Fellowship: City of Hope Surgical Oncology Fellowship (2007) CA
  • Board Certification: American Board of Surgery, General Surgery (2006)
  • Residency: Lenox Hill Hospital General Surgery Residency (2005) NY

Publications

All Publications


  • Institutional variation in recovery after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: An opportunity for enhanced recovery pathways. Journal of surgical oncology Eng, O. S., Blakely, A. M., Lafaro, K. J., Fournier, K. F., Fackche, N. T., Johnston, F. M., Dineen, S., Powers, B., Hendrix, R., Lambert, L. A., Ronnekleiv-Kelly, S., Walle, K. V., Grotz, T. E., Leiting, J. L., Patel, S. H., Dhar, V. K., Baumgartner, J. M., Lowy, A. M., Clarke, C. N., Mogal, H., Zaidi, M. Y., Staley, C. A., Kimbrough, C., Cloyd, J. M., Lee, B., Raoof, M. 2020

    Abstract

    BACKGROUND: Variations in care have been demonstrated both within and among institutions in many clinical settings. By standardizing perioperative practices, Enhanced Recovery After Surgery (ERAS) pathways reduce variation in perioperative care. We sought to characterize the variation in cytoreductive surgery (CRS)/heated intraperitoneal chemotherapy (HIPEC) perioperative practices among experienced US medical centers.METHODS: Data from the US HIPEC Collaborative represents a retrospective multi-institutional cohort study of CRS and CRS/HIPEC procedures performed from 12 major academic institutions. Patient characteristics and perioperative practices were reported and compared. Institutional variation was analyzed using hierarchical mixed-effects linear (continuous outcomes) or logistic (binary outcomes) regression models.RESULTS: A total of 2372 operations were included. CRS/HIPEC was performed most commonly for appendiceal histologies (64.2%). The rate of complications (overall 56.3%, range: 31.8-70.9) and readmissions (overall 20.6%, range: 8.9-33.3) varied by institution (P<.001). Institution-level variation in perioperative practice patterns existed among measured ERAS pathway process/outcomes (P<.001). The percentages of variation with each process/outcome measure attributable solely to institutional practices ranged from 0.6% to 66.6%.CONCLUSIONS: Significant variation exists in the perioperative care of patients undergoing CRS/HIPEC at major US academic institutions. These findings provide a strong rationale for the investigation of best practices in CRS/HIPEC patients.

    View details for DOI 10.1002/jso.26099

    View details for PubMedID 32627199

  • The Chicago Consensus on peritoneal surface malignancies: Standards CANCER Plana, A., Izquierdo, F. J., Schuitevoerder, D., Abbott, D. E., Abdel-Misih, S., Ahrendt, S. A., Al-Kasspooles, M., Amersi, F., Arrington, A. K., Badgwell, B., Barone, R. M., Baumgartner, J. M., Berri, R. N., Bijelic, L., Bowne, W. B., Blazer, D. G., Brown, C., Catenacci, D., Chan, C. F., Cho, C. S., Choudry, M. A., Clarke, C. N., Cusack, J. C., Dachman, A. H., Deneve, J. L., Dineen, S. P., Eng, O. S., Fernandez, L. J., Fleshman, J., Gamblin, T., Gangi, A., Georgakis, G., Gilbert, E. W., Goodman, M. D., Govindarajan, A., Grotz, T. E., Gushchin, V., Hanna, N., Harmath, C., Hart, J., Hayes-Jordan, A., Husain, A. N., Idrees, K., Ihemelandu, C., In, H., Johnston, F. M., Jiang, D., Kane, J. M., Karakousis, G., Kelly, K. J., Kennedy, T. J., Keutgen, X. M., Kindler, H., Kluger, M. D., Lee, B., Mack, L. A., Maduekwe, U. N., Mak, G. Z., Mammen, J. M., Mathew, M., Melis, M., Melnitchouk, N., Merkow, R. P., Micic, D., Mogal, H., Moller, M. G., Nash, G. M., Oto, A., Pameijer, C. R., Parsad, S., Patel, P., Polite, B. N., Pappas, S. G., Polanco, P. M., Reddy, S. S., Royal, R., Salti, G., Sardi, A., Setia, N., Senthil, M., Sherman, S. K., Sideris, L., Skitzki, J., Snyder, B., Tun, S., Veerapong, J., Votanopoulos, K., White, M. G., Winer, J. H., Xiao, S., Yantiss, R. K., Ahuja, N., Lowy, A. M., Alexander, H., Esquivel, J., Foster, J. M., Labow, D. M., Lambert, L. A., Levine, E. A., Staley, C., Sugarbaker, P. H., Bartlett, D. L., Turaga, K. K., Chicago Consensus Working Grp 2020

    Abstract

    The Chicago Consensus Working Group provides the following multidisciplinary recommendations for the care of patients with peritoneal surface malignancies. This article focuses on the standards of a peritoneal surface malignancy center, standards of billing and coding, standards of operative reports for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, standards of cytoreductive surgery training, and standards of intraoperative chemotherapy preparation. These guidelines are developed with input from leading experts, including surgical oncologists, medical oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

    View details for DOI 10.1002/cncr.32825

    View details for Web of Science ID 000525982300001

    View details for PubMedID 32282066

  • The Chicago Consensus guidelines for peritoneal surface malignancies: Introduction CANCER Turaga, K. K., Ahuja, N., Alexander, H., Abbott, D. E., Badgwell, B., Baumgartner, J. M., Choudry, M. A., Cusack, J. C., Deneve, J. L., Esquivel, J., Foster, J. M., Hanna, N., Hayes-Jordan, A., Johnston, F. M., Labow, D. M., Lambert, L. A., Lee, B., Levine, E. A., Lowy, A. M., Nash, G. M., Staley, C., Votanopoulos, K. I., Senthil, M., Sugarbaker, P. H., Yamada, S., Bartlett, D. L., Chicago Consensus Working Grp 2020

    Abstract

    The Chicago Consensus Working Group provides multidisciplinary recommendations for the management of peritoneal surface malignancies of various causes. These guidelines are developed with input from leading experts including surgical oncologists, medical oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness of the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence. This article serves as an introduction to this effort.

    View details for DOI 10.1002/cncr.32827

    View details for Web of Science ID 000526994400001

    View details for PubMedID 32282062

  • The Chicago Consensus on peritoneal surface malignancies: Management of desmoplastic small round cell tumor, breast, and gastrointestinal stromal tumors CANCER Izquierdo, F. J., Plana, A., Schuitevoerder, D., Hayes-Jordan, A., Deneve, J. L., Al-Kasspooles, M., Bowne, W. B., Brown, C., Kane, J. M., Kelly, K. J., Kennedy, T. J., Maduekwe, U. N., Mak, G. Z., Melis, M., Royal, R., Abbott, D. E., Abdel-Misih, S., Amersi, F., Arrington, A. K., Badgwell, B., Barone, R. M., Baumgartner, J. M., Berri, R. N., Bijelic, L., Blazer, D. G., Catenacci, D., Chan, C. F., Cho, C. S., Choudry, M. A., Clarke, C. N., Cusack, J. C., Dachman, A. H., Dineen, S. P., Eng, O. S., Fernandez, L. J., Fleshman, J., Gamblin, T., Gangi, A., Georgakis, G., Gilbert, E. W., Goodman, M. D., Govindarajan, A., Grotz, T. E., Gushchin, V., Hanna, N., Harmath, C., Husain, A. N., Idrees, K., Ihemelandu, C., Jiang, D., Johnston, F. M., Lowy, A. M., Karakousis, G., Keutgen, X. M., Kindler, H., Kluger, M. D., Lee, B., Mack, L. A., Mammen, J. M., Mathew, M., Melnitchouk, N., Merkow, R. P., Mogal, H., Moller, M. G., Oto, A., Pameijer, C. R., Pappas, S. G., Polanco, P. M., Polite, B. N., Reddy, S. S., Salti, G., Sardi, A., Senthil, M., Setia, N., Sideris, L., Sherman, S. K., Skitzki, J., Tun, S., Veerapong, J., Votanopoulos, K., White, M. G., Winer, J. H., Xiao, S., Yantiss, R. K., Ahuja, N., Alexander, H., Esquivel, J., Foster, J. M., Labow, D. M., Lambert, L. A., Levine, E. A., Staley, C., Sugarbaker, P. H., Bartlett, D. L., Turaga, K. K., Chicago Consensus Working Grp 2020

    Abstract

    The Chicago Consensus Working Group provides multidisciplinary recommendations for the management of desmoplastic small round cell, breast, and gastrointestinal stromal tumors specifically related to peritoneal surface malignancy. These guidelines are developed with input from leading experts, including surgical oncologists, medical oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

    View details for DOI 10.1002/cncr.32856

    View details for Web of Science ID 000525984000001

    View details for PubMedID 32282072

  • The Chicago Consensus on peritoneal surface malignancies: Management of gastric metastases CANCER Izquierdo, F. J., Schuitevoerder, D., Plana, A., Eng, O. S., Sherman, S. K., Badgwell, B., Johnston, F. M., Abdel-Misih, S., Blazer, D. G., Dineen, S. P., Gleisner, A., Grotz, T. E., Hanna, N., Mogal, H., Moeller, M. G., Reddy, S. S., Senthil, M., Winer, J. H., Abbott, D. E., Ahrendt, S. A., Al-Kasspooles, M., Alpert, L., Amersi, F., Arrington, A. K., Barone, R. M., Baumgartner, J. M., Berri, R. N., Bijelic, L., Bowne, W. B., Brown, C., Catenacci, D., Chan, C. F., Cho, C. S., Choudry, M. A., Clarke, C. N., Cloyd, J. M., Cusack, J. C., Dachman, A. H., Deneve, J. L., Fernandez, L. J., Fleshman, J., Gamblin, T., Gangi, A., Georgakis, G., Gilbert, E. W., Goodman, M. D., Govindarajan, A., Gushchin, V., Harmath, C., Hayes-Jordan, A., Husain, A. N., Idrees, K., Ihemelandu, C., In, H., Jiang, D., Kane, J. M., Karakousis, G., Kelly, K. J., Kennedy, T. J., Keutgen, X. M., Kindler, H., Kluger, M. D., Lee, B., Mack, L. A., Maduekwe, U. N., Mak, G. Z., Mammen, J. M., Mathew, M., Melis, M., Melnitchouk, N., Merkow, R. P., Oto, A., Pameijer, C. R., Polanco, P. M., Pappas, S. G., Polite, B. N., Royal, R., Salti, G., Sardi, A., Setia, N., Sideris, L., Skitzki, J., Veerapong, J., Votanopoulos, K., White, M. G., Xiao, S., Yantiss, R. K., Ahuja, N., Lowy, A. M., Sugarbaker, P. H., Staley, C., Labow, D. M., Foster, J. M., Esquivel, J., Alexander, H., Levine, E. A., Lambert, L. A., Bartlett, D. L., Turaga, K. K., Chicago Consensus Working Grp 2020

    Abstract

    The Chicago Consensus Working Group provides multidisciplinary recommendations for the management of gastric cancer specifically as it relates to the management of peritoneal surface malignancy. These guidelines are developed with input from leading experts, including surgical oncologists, medical oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness of the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

    View details for DOI 10.1002/cncr.32868

    View details for Web of Science ID 000525978700001

    View details for PubMedID 32282074

  • The Chicago Consensus on peritoneal surface malignancies: Management of neuroendocrine tumors CANCER Schuitevoerder, D., Plana, A., Izquierdo, F. J., Lambert, L. A., Keutgen, X. M., Deneve, J. L., Ahrendt, S. A., Al-Kasspooles, M., Amersi, F., Bowne, W. B., Brown, C., Hayes-Jordan, A., Kane, J. M., Kelly, K. J., Kennedy, T. J., Maduekwe, U. N., Mak, G. Z., Melis, M., Royal, R., Abbott, D. E., Abdel-Misih, S., Alpert, L., Arrington, A. K., Badgwell, B., Barone, R. M., Baumgartner, J. M., Berri, R. N., Bijelic, L., Blazer, D. G., Catenacci, D., Chan, C. F., Cho, C. S., Choudry, M. A., Clarke, C. N., Cusack, J. C., Dachman, A. H., Dineen, S. P., Eng, O. S., Fernandez, L. J., Fleshman, J., Gamblin, T., Gangi, A., Georgakis, G., Gilbert, E. W., Goodman, M. D., Govindarajan, A., Grotz, T. E., Gushchin, V., Hanna, N., Harmath, C., Husain, A. N., Idrees, K., Ihemelandu, C., In, H., Jiang, D., Johnston, F. M., Karakousis, G., Kindler, H., Kluger, M. D., Lee, B., Liao, C., Mack, L. A., Mammen, J. M., Mathew, M., Melnitchouk, N., Merkow, R. P., Mogal, H., Moeller, M. G., Oto, A., Pameijer, C. R., Pappas, S. G., Polanco, P. M., Polite, B. N., Reddy, S. S., Salti, G., Sardi, A., Senthil, M., Setia, N., Sherman, S. K., Sideris, L., Skitzki, J., Tun, S., Veerapong, J., Votanopoulos, K., White, M. G., Winer, J. H., Xiao, S., Yantiss, R. K., Ahuja, N., Lowy, A. M., Alexander, H., Esquivel, J., Foster, J. M., Labow, D. M., Levine, E. A., Staley, C., Sugarbaker, P. H., Bartlett, D. L., Turaga, K. K. 2020

    Abstract

    The Chicago Consensus Working Group provides multidisciplinary recommendations for the management of neuroendocrine tumors specifically related to the management of peritoneal surface malignancy. These guidelines are developed with input from leading experts, including surgical oncologists, medical oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

    View details for DOI 10.1002/cncr.32865

    View details for Web of Science ID 000525975100001

    View details for PubMedID 32282069

  • The Chicago Consensus on peritoneal surface malignancies: Palliative care considerations CANCER Plana, A., Izquierdo, F. J., Schuitevoerder, D., Lambert, L. A., Micic, D., Deneve, J. L., Ahrendt, S. A., Al-kasspooles, M., Amersi, F., Bowne, W. B., Brown, C., Hayes-Jordan, A., Kane, J. M., Kelly, K. J., Kennedy, T. J., Maduekwe, U. N., Mak, G. Z., Melis, M., Royal, R., Abbott, D. E., Abdel-Misih, S., Arrington, A. K., Badgwell, B., Barone, R. M., Baumgartner, J. M., Berri, R. N., Bijelic, L., Blazer, D. G., Catenacci, D., Chan, C., Cho, C. S., Choudry, M. A., Clarke, C. N., Cusack, J. C., Dachman, A. H., Dineen, S. P., Eng, O. S., Fernandez, L. J., Fleshman, J., Gamblin, T., Gangi, A., Georgakis, G., Gilbert, E. W., Goodman, M. D., Govindarajan, A., Grotz, T. E., Gushchin, V., Hanna, N., Harmath, C., Husain, A. N., Idrees, K., Ihemelandu, C., In, H., Johnston, F. M., Jiang, D., Karakousis, G., Keutgen, X. M., Kindler, H., Kluger, M. D., Lee, B., Lee, N., Liao, C., Mack, L. A., Malec, M., Mammen, J., Mathew, M., Melnitchouk, N., Merkow, R. P., Mogal, H., Moller, M. G., Nash, G. M., Oto, A., Pameijer, C. R., Pappas, S. G., Polanco, P. M., Polite, B. N., Reddy, S. S., Salti, G., Sardi, A., Semrad, C., Senthil, M., Setia, N., Sherman, S. K., Sideris, L., Skitzki, J., Veerapong, J., Votanopoulos, K., White, M. G., Winer, J. H., Xiao, S., Yantiss, R. K., Ahuja, N., Lowy, A. M., Alexander, H., Esquivel, J., Foster, J. M., Labow, D. M., Levine, E. A., Staley, C., Sugarbaker, P. H., Bartlett, D. L., Turaga, K. K., Chicago Consensus Working Grp 2020

    Abstract

    The Chicago Consensus Working Group provides multidisciplinary recommendations for palliative care specifically related to peritoneal surface malignancies. These guidelines are developed with input from leading experts including surgical oncologists, medical oncologists, gynecologic oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

    View details for DOI 10.1002/cncr.32826

    View details for Web of Science ID 000525983400001

    View details for PubMedID 32282059

  • The Chicago Consensus on peritoneal surface malignancies: Management of colorectal metastases CANCER Izquierdo, F. J., Schuitevoerder, D., Plana, A., Sherman, S. K., White, M. G., Baumgartner, J. M., Choudry, M. A., Abbott, D. E., Barone, R. M., Berri, R. N., Chan, C. F., Clarke, C. N., Cloyd, J. M., Fleshman, J. W., Georgakis, G., Idrees, K., In, H., Melnitchouk, N., Salti, G., Veerapong, J., Abdel-Misih, S., Ahrendt, S. A., Alpert, L., Al-Kasspooles, M., Amersi, F., Arrington, A. K., Badgwell, B., Bijelic, L., Blazer, D. G., Bowne, W. B., Brown, C., Catenacci, D., Cho, C. S., Cusack, J. C., Dachman, A. H., Deneve, J. L., Dineen, S. P., Eng, O. S., Fernandez, L. J., Gamblin, T., Gangi, A., Gilbert, E. W., Goodman, M. D., Govindarajan, A., Grotz, T. E., Gushchin, V., Hayes-Jordan, A., Hanna, N., Harmath, C., Husain, A. N., Ihemelandu, C., Jiang, D., Johnston, F. M., Iii, J., Karakousis, G., Kelly, K. J., Kennedy, T. J., Keutgen, X. M., Kluger, M. D., Kindler, H., Lee, B., Mack, L. A., Maduekwe, U. N., Mak, G. Z., Mammen, J. M., Melis, M., Mathew, M., Merkow, R. P., Mogal, H., Moeller, M. G., Nash, G. M., Oto, A., Pameijer, C. R., Pappas, S. G., Polanco, P. M., Polite, B. N., Reddy, S. S., Royal, R., Sardi, A., Senthil, M., Setia, N., Sideris, L., Skitzki, J., Votanopoulos, K., Winer, J. H., Xiao, S., Yantiss, R. K., Ahuja, N., Lowy, A. M., Alexander, H., Esquivel, J., Foster, J. M., Labow, D. M., Lambert, L. A., Levine, E. A., Staley, C., Sugarbaker, H., Bartlett, D. L., Turaga, K. K. 2020

    Abstract

    The Chicago Consensus Working Group provides multidisciplinary recommendations for the management of colorectal cancer specifically as it relates to the management of peritoneal surface malignancy. These guidelines are developed with input from leading experts, including surgical oncologists, medical oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

    View details for DOI 10.1002/cncr.32874

    View details for Web of Science ID 000525973400001

    View details for PubMedID 32282070

  • The Chicago Consensus on peritoneal surface malignancies: Management of ovarian neoplasms CANCER Hoppenot, C., Schuitevoerder, D., Izquierdo, F. J., Plana, A., Pothuri, B., Yamada, S., Kim, J., Lee, N., Abbott, D. E., Abdel-Misih, S., Ahrendt, S. A., Al-Kasspooles, M., Amersi, F., Arrington, A. K., Badgwell, B., Barone, R. M., Baumgartner, J. M., Berri, R. N., Bijelic, L., Blazer, D. G., Bowne, W. B., Brown, C., Catenacci, D., Chan, C. F., Chapel, D. B., Cho, C. S., Choudry, M. A., Clarke, C. N., Cusack, J. C., Dachman, A. H., Deneve, J. L., Dineen, S. P., Eng, O. S., Fernandez, L. J., Fleshman, J., Gamblin, T., Gangi, A., Georgakis, G., Gilbert, E. W., Goodman, M. D., Grotz, T. E., Gushchin, V., Hanna, N., Harmath, C., Hayes-Jordan, A., Husain, A. N., Idrees, K., Ihemelandu, C., Johnston, F. M., Jiang, D., Iii, J., Karakousis, G., Kelly, K. J., Kennedy, T. J., Keutgen, X. M., Kindler, H., Kluger, M. D., Lastra, R. R., Lee, B., Mack, L. A., Maduekwe, U. N., Mak, G. Z., Mammen, J. M., Mathew, M., Melis, M., Melnitchouk, N., Merkow, R. P., Mogal, H., Moeller, M. G., Moroney, J., Oto, A., Pameijer, C. R., Pappas, S. G., Polanco, P. M., Polite, B. N., Reddy, S. S., Royal, R., Salti, G., Sardi, A., Senthil, M., Setia, N., Sherman, S. K., Sideris, L., Skitzki, J., Tun, S., Veerapong, J., Votanopoulos, K., White, M. G., Winer, J. H., Xiao, S., Yantiss, R. K., Ahuja, N., Lowy, A. M., Alexander, H., Esquivel, J., Foster, J. M., Labow, D. M., Lambert, L. A., Levine, E. A., Staley, C., Sugarbaker, P. H., Bartlett, D. L., Turaga, K. K. 2020

    Abstract

    The Chicago Consensus Working Group provides multidisciplinary recommendations for the management of ovarian neoplasms specifically related to the management of peritoneal surface malignancy. These guidelines are developed with input from leading experts, including surgical oncologists, medical oncologists, gynecologic oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

    View details for DOI 10.1002/cncr.32867

    View details for Web of Science ID 000525974000001

    View details for PubMedID 32282068

  • The Chicago Consensus on peritoneal surface malignancies: Management of peritoneal mesothelioma CANCER Schuitevoerder, D., Izquierdo, F. J., Plana, A., Nash, G. M., Fernandez, L. J., Kluger, M. D., Mack, L. A., Mammen, J. M., Pameijer, C. R., Polanco, P. M., Sideris, L., Skitzki, J., Abbott, D. E., Abdel-Misih, S., Ahrendt, S. A., Al-Kasspooles, M., Amersi, F., Arrington, A. K., Badgwell, B., Barone, R. M., Baumgartner, J. M., Berri, R. N., Bijelic, L., Blazer, D. G., Bowne, W. B., Brown, C., Catenacci, D., Chan, C. F., Chandler, C. S., Chapel, D. B., Cho, C. S., Choudry, M. A., Clarke, C. N., Cusack, J. C., Dachman, A. H., Deneve, J. L., Dineen, S. P., Eng, O. S., Fleshman, J., Gamblin, T., Gangi, A., Georgakis, G., Gilbert, E. W., Goodman, M. D., Govindarajan, A., Grotz, T. E., Gushchin, V., Hanna, N., Harmath, C., Hayes-Jordan, A., Husain, A. N., Idrees, K., Ihemelandu, C., In, H., Jiang, D., Johnston, F. M., Kane, J. M., Karakousis, G., Kelly, K. J., Kennedy, T. J., Keutgen, X. M., Kindler, H., Lee, B., Maduekwe, U. N., Mak, G. Z., Melis, M., Melnitchouk, N., Mathew, M., Merkow, R. P., Mogal, H., Moller, M. G., Oto, A., Pappas, S. G., Polite, B. N., Reddy, S. S., Royal, R., Salti, G., Sardi, A., Senthil, M., Setia, N., Sherman, S. K., Veerapong, J., Votanopoulos, K., White, M. G., Winer, J. H., Xiao, S., Yantiss, R. K., Ahuja, N., Lowy, A. M., Alexander, H., Esquivel, J., Foster, J. M., Labow, D. M., Lambert, L. A., Levine, E. A., Staley, C., Sugarbaker, P. H., Bartlett, D. L., Turaga, K. K., Chicago Consensus Working Grp 2020

    Abstract

    The Chicago Consensus Working Group provides multidisciplinary recommendations for the management of peritoneal mesothelioma. These guidelines are developed with input from leading experts, including surgical oncologists, medical oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness of the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

    View details for DOI 10.1002/cncr.32870

    View details for Web of Science ID 000525990200001

    View details for PubMedID 32282077

  • The Chicago Consensus on peritoneal surface malignancies: Management of appendiceal neoplasms CANCER Schuitevoerder, D., Plana, A., Izquierdo, F. J., Votanopoulos, K., Cusack, J. C., Bijelic, L., Cho, C. S., Gangi, A., Gilbert, E. W., Goodman, M. D., Govindarajan, A., Gushchin, V., Ihemelandu, C., Kelly, K. J., Merkow, R. P., Pappas, S. G., Abbott, D. E., Ahrendt, S. A., Al-Kasspooles, M., Alpert, L., Amersi, F., Arrington, A. K., Badgwell, B., Barone, R. M., Baumgartner, J. M., Blazer, D. G., Berri, R. N., Brown, C., Catenacci, D., Chan, C. F., Choudry, M. A., Clarke, C. N., Cloyd, J. M., Dachman, A. H., Deneve, J. L., Dineen, S. P., Fernandez, L. J., Eng, O. S., Fleshman, J. W., Gamblin, T., Georgakis, G., Grotz, T. E., Hanna, N., Harmath, C., Hart, J., Hayes-Jordan, A., Husain, A. N., Idrees, K., In, H., Jiang, D., Kane, J. M., Kennedy, T. J., Keutgen, X. M., Kindler, H., Lee, B., Liao, C., Maduekwe, U. N., Mak, G. Z., Mack, L. A., Mathew, M., Melis, M., Melnitchouk, N., Misdraji, J., Mogal, H., Moller, M. G., Nash, G. M., Oto, A., Pai, R. K., Pameijer, C. R., Polanco, P. M., Polite, B. N., Reddy, S. S., Royal, R., Ryan, D. P., Salti, G., Sardi, A., Senthil, M., Setia, N., Sherman, S. K., Sideris, L., Skitzki, J., Veerapong, J., White, M. G., Winer, J. H., Xiao, S., Yantiss, R. K., Ahuja, N., Bowne, W., Lowy, A. M., Alexander, H., Esquivel, J., Foster, J. M., Labow, D. M., Lambert, L. A., Levine, E. A., Staley, C., Sugarbaker, P. H., Bartlett, D. L., Turaga, K. K., Chicago Consensus Working Grp 2020

    Abstract

    The Chicago Consensus Working Group provides multidisciplinary recommendations for the management of appendiceal neoplasms specifically related to the management of peritoneal surface malignancies. These guidelines are developed with input from leading experts, including surgical oncologists, medical oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

    View details for DOI 10.1002/cncr.32881

    View details for Web of Science ID 000525979800001

    View details for PubMedID 32282073

  • Does Lymphadenectomy Extent Impact Survival in Small Bowel Neuroendocrine Tumors? De Andrade, J., Blakely, A., Nguyen, A., Ituarte, P., Li, D., Lee, B., Singh, G. LIPPINCOTT WILLIAMS & WILKINS. 2020: 467
  • Gastro-Entero-Pancreatic Neuroendocrine Tumors in Young Adults - Fare Better Than Older Patients Nguyen, A., Stewart, C., Larocca, C., De Andrade, J., Ituarte, P., Lee, B., Chang, S., Kessler, J., Li, D., Singh, G. LIPPINCOTT WILLIAMS & WILKINS. 2020: 481?82
  • NETS Arising in a Meckel's Diverticulum: Do They Behave Differently Than Ileal NETS? De Andrade, J., Blakely, A., Nguyen, A., Singh, G., Lee, B., Ituarte, P. LIPPINCOTT WILLIAMS & WILKINS. 2020: 466?67
  • Prognostic impact of tumor location in resected gallbladder cancer: A national cohort analysis. Journal of surgical oncology Lafaro, K., Blakely, A. M., Melstrom, L. G., Warner, S. G., Lee, B., Singh, G., Fong, Y., Raoof, M. 2020

    Abstract

    Tumor location (peritoneal vs hepatic) has been incorporated in the 8th edition of the American Joint Committee on Cancer Staging system for gallbladder cancer. However, larger studies are needed to confirm the prognostic impact of tumor location.Patients with pathologically-confirmed gallbladder cancer with information on primary tumor location were included from the National Cancer Database (2009-2012). We compared patients with hepatic-side tumors to those on the peritoneal side. Survival data were plotted using the Kaplan-Meier method. Prognostic factors were modeled with a multivariate Cox Proportional Hazards Model. Primary outcome was overall survival (OS).A total of 1251 patients were included. In comparison to patients with peritoneal-sided tumors, patients with hepatic-sided tumors were more likely to: be of higher pT stage (pT3: 49% vs 24%; P?

    View details for DOI 10.1002/jso.26107

    View details for PubMedID 32652555

  • Impact of Neoadjuvant Chemotherapy on the Outcomes of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Peritoneal Metastases: A Multi-Institutional Retrospective Review. Journal of clinical medicine Beal, E. W., Suarez-Kelly, L. P., Kimbrough, C. W., Johnston, F. M., Greer, J., Abbott, D. E., Pokrzywa, C., Raoof, M., Lee, B., Grotz, T. E., Leiting, J. L., Fournier, K., Lee, A. J., Dineen, S. P., Powers, B., Veerapong, J., Baumgartner, J. M., Clarke, C., Mogal, H., Russell, M. C., Zaidi, M. Y., Patel, S. H., Dhar, V., Lambert, L., Hendrix, R. J., Hays, J., Abdel-Misih, S., Cloyd, J. M. 2020; 9 (3)

    Abstract

    Cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with improved survival for patients with colorectal peritoneal metastases (CR-PM). However, the role of neoadjuvant chemotherapy (NAC) prior to CRS-HIPEC is poorly understood. A retrospective review of adult patients with CR-PM who underwent CRS+/-HIPEC from 2000-2017 was performed. Among 298 patients who underwent CRS+/-HIPEC, 196 (65.8%) received NAC while 102 (34.2%) underwent surgery first (SF). Patients who received NAC had lower peritoneal cancer index score (12.1 + 7.9 vs. 14.3 + 8.5, p = 0.034). There was no significant difference in grade III/IV complications (22.4% vs. 16.7%, p = 0.650), readmission (32.3% vs. 23.5%, p = 0.114), or 30-day mortality (1.5% vs. 2.9%, p = 0.411) between groups. NAC patients experienced longer overall survival (OS) (median 32.7 vs. 22.0 months, p = 0.044) but similar recurrence-free survival (RFS) (median 13.8 vs. 13.0 months, p = 0.456). After controlling for confounding factors, NAC was not independently associated with improved OS (OR 0.80) or RFS (OR 1.04). Among patients who underwent CRS+/-HIPEC for CR-PM, the use of NAC was associated with improved OS that did not persist on multivariable analysis. However, NAC prior to CRS+/-HIPEC was a safe and feasible strategy for CR-PM, which may aid in the appropriate selection of patients for aggressive cytoreductive surgery.

    View details for DOI 10.3390/jcm9030748

    View details for PubMedID 32164300

  • Repeat Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Is Not Associated with Prohibitive Complications: Results of a Multiinstitutional Retrospective Study. Annals of surgical oncology Powers, B. D., Felder, S., Veerapong, J., Baumgartner, J. M., Clarke, C., Mogal, H., Staley, C. A., Maithel, S. K., Patel, S., Dhar, V., Lambert, L., Hendrix, R. J., Abbott, D. E., Pokrzywa, C., Raoof, M., Lee, B., Johnston, F. M., Greer, J., Cloyd, J. M., Kimbrough, C., Grotz, T., Leiting, J., Fournier, K., Lee, A. J., Imanirad, I., Dessureault, S., Dineen, S. P. 2020

    Abstract

    Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is offered to select patients with peritoneal metastases. In instances of recurrence/progression, a repeat CRS/HIPEC may be considered. The perioperative morbidity and the potential oncologic benefits are not well described.We performed a retrospective analysis of a multiinstitutional database to assess the perioperative outcomes following repeat CRS/HIPEC (repeat). Kaplan-Meier and Cox estimates were used to assess survival.In the entire cohort, 2157 patients were analyzed, with 158 (7.3%) in the repeat cohort. The rate of complete cytoreduction was 89.8% versus 83.0% in initial versus repeat groups. The overall incidence of major complications was similar (26.3% vs. 30.7%); however, reoperation was more common in the repeat group. Perioperative outcomes such as length of stay and nonhome discharge were not significantly different. For the entire cohort, 5-year overall survival (OS) was 56.0% in the initial group and 59.5% in the repeat group. In patients with only appendiceal cancer, we observed a 5-year OS of 64.0% in the initial group compared with 67.3% in the repeat cohort. For patients with appendiceal cancer who developed a recurrence/progression, median OS was 36 months in the no repeat operation group compared with 73 months for those that did. Multivariable regression demonstrated that completeness of cytoreduction and tumor grade were associated with OS, but repeat operation was not.Repeat CRS/HIPEC is not associated with prohibitive risk. Survival is possibly improved, and therefore, repeat operation should be considered in selected patients with recurrent or progressive disease.

    View details for DOI 10.1245/s10434-020-08482-x

    View details for PubMedID 32318945

  • National postoperative and oncologic outcomes after pelvic exenteration for T4b rectal cancer. Journal of surgical oncology Konstantinidis, I. T., Lee, B., Trisal, V., Paz, I., Melstrom, K., Sentovich, S., Lai, L., Raoof, M. 2020

    Abstract

    Studies reporting outcomes after pelvic exenteration for rectal cancer are limited. The objective of this study was to evaluate early postoperative and oncologic outcomes in a national multi-institutional cohort.Using the National Cancer Database (NCDB), which collects data from over 1500 commission on cancer (CoC)-accredited hospitals, we analyzed patients undergoing pelvic exenteration for T4b rectal adenocarcinoma.There were 1367 pelvic exenterations performed in 552 hospitals. Median age was 60 years, the majority of patients (n?=?831; 60.8%) were female. Neoadjuvant radiation was used only in 57%; 24.3% of resections had positive margins. Following exenteration, 30-day mortality rate, 90-day mortality rate, and readmission rates were: 1.8%, 4.4%, and 7.4%. Age???60 years and higher Charlson-Deyo comorbidity index were independently associated with increased 90-day mortality (P?

    View details for DOI 10.1002/jso.26058

    View details for PubMedID 32516469

  • Predictors of Nonhome Discharge after Cytoreductive Surgery and HIPEC. The Journal of surgical research Kubi, B., Gunn, J., Fackche, N., Cloyd, J. M., Abdel-Misih, S., Grotz, T., Leiting, J., Fournier, K., Lee, A. J., Dineen, S., Dessureault, S., Veerapong, J., Baumgartner, J. M., Clarke, C., Mogal, H., Patel, S. H., Dhar, V., Lambert, L., Hendrix, R. J., Abbott, D. E., Pokrzywa, C., Raoof, M., Lee, B., Maithel, S. K., Staley, C. A., Johnston, F. M., Wang, N. Y., Greer, J. B. 2020; 255: 475?85

    Abstract

    Using a national database of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) recipients, we sought to determine risk factors for nonhome discharge (NHD) in a cohort of patients.Patients undergoing CRS/HIPEC at any one of 12 participating sites between 2000 and 2017 were identified. Univariate analysis was used to compare the characteristics, operative variables, and postoperative complications of patients discharged home and patients with NHD. Multivariate logistic regression was used to identify independent risk factors of NHD.The cohort included 1593 patients, of which 70 (4.4%) had an NHD. The median [range] peritoneal cancer index in our cohort was 14 [0-39]. Significant predictors of NHD identified in our regression analysis were advanced age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.05-1.12; P < 0.001), an American Society of Anesthesiologists (ASA) score of 4 (OR, 2.87; 95% CI, 1.21-6.83; P = 0.017), appendiceal histology (OR, 3.14; 95% CI 1.57-6.28; P = 0.001), smoking history (OR, 3.22; 95% CI, 1.70-6.12; P < 0.001), postoperative total parenteral nutrition (OR, 3.14; 95% CI, 1.70-5.81; P < 0.001), respiratory complications (OR, 7.40; 95% CI, 3.36-16.31; P < 0.001), wound site infections (OR, 3.12; 95% CI, 1.58-6.17; P = 0.001), preoperative hemoglobin (OR, 0.81; 95% CI, 0.70-0.94; P = 0.006), and total number of complications (OR, 1.41; 95% CI, 1.16-1.73; P < 0.001).Early identification of patients at high risk for NHD after CRS/HIPEC is key for preoperative and postoperative counseling and resource allocation, as well as minimizing hospital-acquired conditions and associated health care costs.

    View details for DOI 10.1016/j.jss.2020.05.085

    View details for PubMedID 32622162

  • Pilot study of a telehealth perioperative physical activity intervention for older adults with cancer and their caregivers. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer Lafaro, K. J., Raz, D. J., Kim, J. Y., Hite, S., Ruel, N., Varatkar, G., Erhunmwunsee, L., Melstrom, L., Lee, B., Singh, G., Fong, Y., Sun, V. 2019

    Abstract

    BACKGROUND: Older adults undergoing cancer surgery are at greater risk for poor postoperative outcomes. Caregivers also endure significant burden. Participation in perioperative physical activity may improve physical functioning and enhance overall well-being for both patients and caregivers. In this study, we assessed the feasibility of a personalized telehealth intervention to enhance physical activity for older (?65years) gastrointestinal (GI) and lung cancer surgery patients/caregivers.METHODS: Participants completed four telehealth sessions with physical therapy/occupational therapy (PT/OT) before surgery and up to 2weeks post-discharge. Outcomes included preop geriatric assessment, functional measures, and validated measures for symptoms and psychological distress. Pre/post-intervention trends/trajectories for outcomes were explored.RESULTS: Thirty-four patient/caregiver dyads (16, GI; 18, lung) were included. Accrual rate was 76% over 8months; retention rate was 88% over 2months. Median for postop of a 6-min walk test, timed up and go, and short physical performance battery test scores improved from baseline to postop. Participant satisfaction scores were high.CONCLUSION: Our conceptually based, personalized, multimodal, telehealth perioperative physical activity intervention for older patient/caregiver dyads is feasible and acceptable. It offers an opportunity to improve postoperative outcomes by promoting functional recovery through telehealth, behavior change, and self-monitoring approaches.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03267524.

    View details for DOI 10.1007/s00520-019-05230-0

    View details for PubMedID 31845007

  • Appendiceal Cancer: Comparison of Patients Presenting Initially for Definitive Operation with Those Presenting after Prior Non-Curative Resection Blakely, A. M., LaRocca, C. J., Eng, O. S., Ituarte, P., Lee, B., Raoof, M. ELSEVIER SCIENCE INC. 2019: S255?S256
  • Neuroendocrine Tumors of Meckel's Diverticula: Rare but Fare Well AMERICAN SURGEON De Andrade, J. P., Blakely, A. M., Nguyen, A. H., Ituarte, P. G., Warner, S. G., Melstrom, L. G., Lee, B., Singh, G. 2019; 85 (10): 1125?28

    Abstract

    Neuroendocrine tumors (NETs) are the most common malignancy arising in Meckel's diverticula (MDs). To date, there are no large series characterizing these tumors. The National Cancer Database was queried for patients with MD NETs (n = 162) from 2004 to 2014. Patient and tumor characteristics as well as outcomes were analyzed. MD NETs were more common in men (72.8%) at a median age of 62 years; 95.1 per cent of patients were white. All patients underwent surgery. Clinical M0 disease was present in 97.4 per cent of patients, and 88.2 per cent of tumors were well differentiated. Lymphovascular invasion was present in 13.2 per cent. Most (60.4%) tumors were less than 10 mm. Lymphadenectomy was performed in 32.9 per cent of patients, with 52.1 per cent of these found to have metastatic lymph node disease. Although most MD NETs are well differentiated, smaller than 10 mm, and do not have lymphovascular invasion, lymph node metastases are commonly found, suggesting that mesenteric lymphadenectomy with adequate resection of the small bowel may be necessary for adequate staging and disease clearance.

    View details for Web of Science ID 000493286700010

    View details for PubMedID 31657307

  • Synchronous Small Bowel Neuroendocrine Tumors with Liver Metastases: Are Combined Resections Safe? De Andrade, J. P., Lafaro, K. J., Ituarte, P. G., Lee, B., Singh, G. ELSEVIER SCIENCE INC. 2019: E15
  • Multivisceral robotic liver surgery: feasible and safe. Journal of robotic surgery Konstantinidis, I. T., Raoof, M., Zheleva, V., Lafaro, K., Lau, C., Fong, Y., Lee, B. 2019

    Abstract

    The application of robotic technology allows for the performance of multi-organ liver resections by multidisciplinary teams in a minimally invasive manner. Their technique and outcomes are not established. Herein we describe our technique with robotic liver surgery combined with colon, pancreas and urologic resections. Our patients are an 84-year-old (yo) female (Body Mass Index, BMI: 25) with a recently diagnosed right colon adenocarcinoma and two synchronous liver metastases at segments 5 and 6, a 75-year-old female (BMI: 50.4) with a history of right renal cell cancer status post (s/p) right robotic radical nephrectomy now with tumor recurrence with multiple intra-abdominal masses including a segment 7 liver lesion and a 71-year-old female (BMI: 24) with history of pancreatic ductal adenocarcinoma of the tail and a segment 3 liver lesion s/p neoadjuvant chemotherapy. The Xi robotic system (Intuitive Surgical, Sunnyvale, CA, USA) was utilized in all cases. Port placement in all cases was decided within the multidisciplinary teams to accommodate both the hepatic and the extra-hepatic portion of the operation. Parenchymal transections were performed with the use of the Vessel Sealer and the robotic stapler as appropriate. Indocyanine green (ICG) was used to assess the anastomotic perfusion in the first patient. Blood loss was 50ml for the first two cases and 300ml for the third. Surgical margins were negative in all cases. Patients were discharged at POD 8, 3 and 5 with one patient experiencing postoperative ileus. Robotic multivisceral liver resections are feasible and safe within multidisciplinary surgical teams with expertise in robotic surgery. The robotic platform can offer a minimally invasive approach in liver surgery synchronous with colonic, pancreatic and urologic surgery.

    View details for DOI 10.1007/s11701-019-01017-x

    View details for PubMedID 31489535

  • Preoperative Risk Score for Predicting Incomplete Cytoreduction: A 12-Institution Study from the US HIPEC Collaborative. Annals of surgical oncology Zaidi, M. Y., Lee, R. M., Gamboa, A. C., Speegle, S., Cloyd, J. M., Kimbrough, C., Grotz, T., Leiting, J., Fournier, K., Lee, A. J., Dineen, S., Dessureault, S., Kelly, K. J., Kotha, N. V., Clarke, C., Gamblin, T. C., Patel, S. H., Lee, T. C., Hendrix, R. J., Lambert, L., Ronnekleiv-Kelly, S., Pokrzywa, C., Blakely, A. M., Lee, B., Johnston, F. M., Fackche, N., Russell, M. C., Maithel, S. K., Staley, C. A. 2019

    Abstract

    For patients with peritoneal carcinomatosis undergoing cytoreductive surgery with heated intraperitoneal chemotherapy (CRS/HIPEC), incomplete cytoreduction (CCR2/3) confers morbidity without survival benefit. The aim of this study is to identify preoperative factors which predict CCR2/3.All patients who underwent curative-intent CRS/HIPEC of low/high-grade appendiceal, colorectal, or peritoneal mesothelioma cancers in the 12-institution US HIPEC Collaborative from 2000 to 2017 were included (n?=?2027). The primary aim is to create an incomplete-cytoreduction risk score (ICRS) to predict CCR2/3 CRS utilizing preoperative data. ICRS was created from a randomly selected cohort of 50% of patients (derivation cohort) and verified on the remaining patients (validation cohort).Within our derivation cohort (n?=?998), histology was low-grade appendiceal neoplasms in 30%, high-grade appendiceal tumor in 41%, colorectal tumor in 22%, and peritoneal mesothelioma in 8%. CCR0/1 was achieved in 816 patients and CCR 2/3 in 116 patients. On multivariable analysis, preoperative factors associated with incomplete cytoreduction were male gender [odds ratio (OR) 3.4, p?=?0.007], presence of ascites (OR 2.8, p?=?0.028), cancer antigen (CA)-125???40 U/mL (OR 3.4, p?=?0.012), and carcinoembryonic antigen (CEA)???4.2 ng/mL (OR 3.2, p?=?0.029). Each preoperative factor was assigned a score of 0 or 1 to form an ICRS from 0 to 4. Scores were grouped as zero (0), low (1-2), or high (3-4). Incidence of CCR2/3 progressively increased by risk group from 1.6% in zero to 13% in low and 39% in high. When ICRS was applied to the validation cohort (n?=?1029), this relationship was maintained.The incomplete cytoreduction risk score incorporates preoperative factors to accurately stratify the risk of CCR2/3 resection in CRS/HIPEC. This score should not be used in isolation, however, to exclude patients from surgery.

    View details for DOI 10.1245/s10434-019-07626-y

    View details for PubMedID 31602579

  • Trends and outcomes of robotic surgery for gastrointestinal (GI) cancers in the USA: maintaining perioperative and oncologic safety. Surgical endoscopy Konstantinidis, I. T., Ituarte, P., Woo, Y., Warner, S. G., Melstrom, K., Kim, J., Singh, G., Lee, B., Fong, Y., Melstrom, L. G. 2019

    Abstract

    Minimally invasive surgery (MIS) continues to gain traction as a feasible approach for the operative management of gastrointestinal (GI) malignancies. The aim of this study is to quantify national trends, perioperative and oncologic outcomes of MIS for the most common GI malignancies including the esophagus, stomach, pancreas, colon, and rectum. We hypothesize that with more widespread use of MIS techniques, perioperative outcomes and oncologic resection quality will remain preserved.The National Cancer Database (2010-2014) was utilized to assess perioperative outcomes and pathologic quality of MIS (robotic and laparoscopic) compared to open, in patients who underwent resection for cancers of the esophagus, stomach, pancreas, colon, and rectum. Multilevel logistic regression models were constructed to identify independent factors associated with postoperative and long-term outcomes.Data from 11,023 esophageal, 30,664 gastric, 30,689 pancreas, 260,669 colon, and 52,239 rectal resections were analyzed. Although laparoscopy is the most prevalent MIS approach, the number of robotic resections increased nearly fourfold from 2010 to 2014 in all organ sites (increase by factor: esophagus: 3.8, stomach: 4.4, pancreas: 4.4, colon: 3.8 and rectum: 4). The number of laparoscopic resections increased at a slower rate (factor: 1.3-1.9), whereas the number of open resections decreased (factor: 0.67-0.77). Patients who underwent robotic-assisted resections were younger for stomach and colorectal resections and with lower Charlson Comorbidity Index across all sites. Patients who underwent robotic or laparoscopic resections had shorter hospitalizations, fewer readmissions (with the exception of rectal resections) and lower postoperative mortality at 90 days. Robotic-assisted resections had comparable negative margin resections and number of lymph nodes to laparoscopic and open resections across all sites.The utilization of robotic-assisted resections of GI cancers is rapidly increasing with more frequent use in younger and healthier patients. This study demonstrates that with the rising utilization of robotic-assisted resections, perioperative outcomes and oncologic safety have not been compromised.

    View details for DOI 10.1007/s00464-019-07284-x

    View details for PubMedID 31820161

  • Predictors of Anastomotic Failure After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Does Technique Matter? Annals of surgical oncology Wiseman, J. T., Kimbrough, C., Beal, E. W., Zaidi, M. Y., Staley, C. A., Grotz, T., Leiting, J., Fournier, K., Lee, A. J., Dineen, S., Powers, B., Veerapong, J., Baumgartner, J. M., Clarke, C., Patel, S. H., Dhar, V., Hendrix, R. J., Lambert, L., Abbott, D. E., Pokrzywa, C., Raoof, M., Lee, B., Fackche, N., Greer, J., Pawlik, T. M., Abdel-Misih, S., Cloyd, J. M. 2019

    Abstract

    Anastomotic failure (AF) after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) remains a dreaded complication. Whether specific factors, including anastomotic technique, are associated with AF is poorly understood.Patients who underwent CRS-HIPEC including at least one bowel resection between 2000 and 2017 from 12 academic institutions were reviewed to determine factors associated with AF (anastomotic leak or enteric fistula).Among 1020 patients who met the inclusion criteria, the median age was 55 years, 43.9% were male, and the most common histology was appendiceal neoplasm (62.3%). The median Peritoneal Cancer Index was 14, and 93.2% of the patients underwent CC0/1 resection. Overall, 82 of the patients (8%) experienced an AF, whereas 938 (92.0%) did not. In the multivariable analysis, the factors associated with AF included male gender (odds ratio [OR], 2.2; p??0.05). Anastomotic failure was associated with longer hospital stay (23 vs 10 days; p?

    View details for DOI 10.1245/s10434-019-07964-x

    View details for PubMedID 31659645

  • The Association of Tumor Laterality and Survival After Cytoreduction for Colorectal Carcinomatosis. The Journal of surgical research Blakely, A. M., Lafaro, K. J., Eng, O. S., Ituarte, P. H., Fakih, M., Lee, B., Raoof, M. 2019; 248: 20?27

    Abstract

    Primary tumor location has emerged as an important surrogate for tumor biology in metastatic colorectal cancer treated with systemic chemotherapy. It is unclear if primary tumor location is associated with survival after cytoreductive surgery (CRS) with or without heated intraperitoneal chemotherapy (HIPEC) for colorectal carcinomatosis.Study of a contemporary cohort merged data from the California Cancer Registry, 2004-2012, and the Office of Statewide Health Planning and Development inpatient database. For patients undergoing CRS/HIPEC, clinicopathologic variables, treatment characteristics, and survival were compared by right versus left colon primary site. Survival was analyzed by Cox proportional hazards.Of 272 patients identified, 128 (47.1%) had right-sided tumors. Left- and right-sided cohorts had similar patient, tumor, and treatment factors. Patients with left-sided primary tumors had significantly prolonged overall survival (mean 34 versus 15.5 mo, P = 0.0010). Factors independently associated with decreased overall survival included age >80 (HR 7.0, P < 0.0001), advanced T4 stage (HR 3.6, P = 0.0031), and positive lymph nodes (HR 2.2, P = 0.0004). Metachronous peritoneal involvement (HR 0.38, P < 0.0001) and left-sided primary tumors (HR 0.72, P = 0.041) were independently associated with improved overall survival.This study identifies location of primary tumor as an important determinant of long-term survival after CRS/HIPEC. Patients with left-sided tumors have a more favorable prognosis.

    View details for DOI 10.1016/j.jss.2019.10.001

    View details for PubMedID 31841733

  • Readmissions After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: a US HIPEC Collaborative Study. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Lee, T. C., Wima, K., Sussman, J. J., Ahmad, S. A., Cloyd, J. M., Ahmed, A., Fournier, K., Lee, A. J., Dineen, S., Powers, B., Veerapong, J., Baumgartner, J. M., Clarke, C., Mogal, H., Zaidi, M. Y., Maithel, S. K., Leiting, J., Grotz, T., Lambert, L., Hendrix, R. J., Abbott, D. E., Pokrzywa, C., Blakely, A. M., Lee, B., Johnston, F. M., Greer, J., Patel, S. H. 2019

    Abstract

    Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) results in significant morbidity and readmissions. Previous studies have been limited by single-institution design or lack of tumor details in the database used.The 12-institution US HIPEC Collaborative Database was queried between 1999 and 2017. Preoperative and intraoperative patient and tumor details were analyzed for associations with readmissions.A total of 2017 of 2372 cases were included in the analysis. The 30-day readmission rate was 15.9% (n = 321). Common indications for readmission included failure to thrive (29.9%), infection (23.6%), and ileus/bowel obstruction (15.1%). The readmitted cohort had more complications, including intra-abdominal abscess (21.2% vs 6.2%), ileus (28.0% vs 17.2%), anastomotic leak (11.2% vs 2.2%), enteric fistula (5.6% vs 1.5%), deep venous thrombosis (6.2% vs 2.5%), and pulmonary embolism (6.9% vs 2.5%). Factors independently associated with readmission (p < 0.05) included ECOG score ? 3 (OR 3.4), depression (OR 2.4), total parenteral nutrition (OR 3.6), low anterior resection or partial colectomy (OR 2.0), and stoma creation (OR 2.2). Factors not associated included neoadjuvant chemotherapy, peritoneal cancer index, and completeness of cytoreduction. Readmission rate between 31 and 90 days was 3.9% (n = 78). Independent predictors (p < 0.05) included operative time (OR 1.1), low anterior resection or partial colectomy (OR 1.7), and stoma creation (OR 2.2).In the largest study to date examining readmissions after CRS-HIPEC, 30-day readmission rate was 15.9%. Tumor factors failed to predict readmission, whereas preoperative functional status and depression along with individual cytoreductive procedures predicted readmission. Patients with these risk factors or postoperative complications may benefit from closer post-discharge monitoring.

    View details for DOI 10.1007/s11605-019-04463-y

    View details for PubMedID 31745888

  • Prognostic significance of Chromogranin A in small pancreatic neuroendocrine tumors. Surgery Raoof, M., Jutric, Z., Melstrom, L. G., Lee, B., Li, D., Warner, S. G., Fong, Y., Singh, G. 2019; 165 (4): 760?66

    Abstract

    The incidence of nonfunctional pancreatic neuroendocrine tumors ?2cm is rising. The biologic behavior of these tumors is variable; thus, their management remains controversial. Chromogranin A upregulation is a useful diagnostic biomarker of neuroendocrine tumors; however, the prognostic significance of Chromogranin A is unclear. The objective of this study was to determine whether Chromogranin A levels have prognostic value in pancreatic neuroendocrine tumor patients and may help guide management.We evaluated the National Cancer Database over a 10-year period (2004-2013). Patients with pancreatic neuroendocrine tumors measuring ?2cm, without distant metastases, were identified and categorized as Chromogranin A high (>420ng/mL) or Chromogranin A low (?420ng/mL), and those lacking data on Chromogranin A levels were excluded from the study. Univariate and multivariate analyses were performed using Cox proportional hazards model. Cut-point determination was performed using the Contal and O'Quigley method.Of the 445 eligible patients, 352 (79%) were Chromogranin A low and 93 (21%) were Chromogranin A high. Median Chromogranin A level was 71ng/mL (interquartile range, 24-294ng/mL). Chromogranin levels were associated with clinical nodal status and grade. Furthermore, on multivariate analysis, Chromogranin A levels (Chromogranin A high versus Chromogranin A low) independently predicted overall survival after controlling for tumor size, grade, clinical nodal status, and academic status of the facility (hazard ratio: 7.90, 95%CI: 2.34-26.69, P?=?.001). The greatest benefit of surgical resection was noted in patients in the Chromogranin A high subgroup (log-rank P <.001).Serum Chromogranin A levels can be incorporated in surgical decision-making for patients with small pancreatic neuroendocrine tumors. Patients in the Chromogranin A low group can be considered for observation, whereas patients in the Chromogranin A high group should be strongly considered for resection.

    View details for DOI 10.1016/j.surg.2018.10.018

    View details for PubMedID 30447803

  • ASO Author Reflections: A Novel Tool to Assess and Describe HIPEC Complications. Annals of surgical oncology Dumitra, S., Lee, B. 2019

    View details for DOI 10.1245/s10434-018-7053-x

    View details for PubMedID 30600405

  • Optimal Surveillance Frequency After CRS/HIPEC for Appendiceal and Colorectal Neoplasms: A Multi-institutional Analysis of the US HIPEC Collaborative. Annals of surgical oncology Gamboa, A. C., Zaidi, M. Y., Lee, R. M., Speegle, S., Switchenko, J. M., Lipscomb, J., Cloyd, J. M., Ahmed, A., Grotz, T., Leiting, J., Fournier, K., Lee, A. J., Dineen, S., Powers, B. D., Lowy, A. M., Kotha, N. V., Clarke, C., Gamblin, T. C., Patel, S. H., Lee, T. C., Lambert, L., Hendrix, R. J., Abbott, D. E., Vande Walle, K., Lafaro, K., Lee, B., Johnston, F. M., Greer, J., Russell, M. C., Staley, C. A., Maithel, S. K. 2019

    Abstract

    No guidelines exist for surveillance following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for appendiceal and colorectal cancer. The primary objective was to define the optimal surveillance frequency after CRS/HIPEC.The U.S. HIPEC Collaborative database (2000-2017) was reviewed for patients who underwent a CCR0/1 CRS/HIPEC for appendiceal or colorectal cancer. Radiologic surveillance frequency was divided into two categories: low-frequency surveillance (LFS) at q6-12mos or high-frequency surveillance (HFS) at q2-4mos. Primary outcome was overall survival (OS).Among 975 patients, the median age was 55 year, 41% were male: 31% had non-invasive appendiceal (n?=?301), 45% invasive appendiceal (n?=?435), and 24% colorectal cancer (CRC; n?=?239). With a median follow-up time of 25 mos, the median time to recurrence was 12 mos. Despite less surveillance, LFS patients had no decrease in median OS (non-invasive appendiceal: 106 vs. 65 mos, p?

    View details for DOI 10.1245/s10434-019-07526-1

    View details for PubMedID 31243668

  • Lymphovascular Invasion Predicts Lymph Node Involvement in Small Pancreatic Neuroendocrine Tumors. Neuroendocrinology Blakely, A., Lafaro, K., Li, D., Kessler, J., Chang, S., Ituarte, P., Lee, B., Singh, G. 2019

    Abstract

    Pancreatic neuroendocrine tumors (PNETs) are increasing in incidence, and prognostic factors continue to evolve. The benefit of lymphadenectomy for PNETs ?2 cm remains unclear. We sought to determine the significance of lymphovascular invasion (LVI) for small PNETs.The National Cancer Database was queried for patients with PNETs ?2 cm and with ?1 evaluated lymph node (LN), years 2004-2015. Demographic, clinical, and treatment characteristics were analyzed. Multivariate logistic regression was performed to identify predictors of LN positivity.Among 2,499 patients identified, tumor location was delineated as the head (26%), body (18%), tail (38%), or unspecified (18%); 74% were well-differentiated versus 10% moderate, 2% poor, and 14% unknown. LVI occurred in 11%. A median of 9 LN were evaluated; overall positivity was 18%. Mean survival was significantly longer in node-negative patients (115 versus 95 months, log-rank p<0.0001). LVI was the strongest predictor of node involvement (OR 10.4, p<0.0001) when controlling for tumor size, grade, and location. Subset analysis of patients with known LVI status, grade, location, and mitoses found that LVI was more likely in the setting of moderate-to-high tumor grade, 1-2 cm size, pancreatic head location, and high mitotic rate. Among patients with ?2 of these four factors, 25% were node-positive.Presence of LVI was the strongest predictor of node positivity. LVI on endoscopic biopsy should prompt resection and regional lymph node dissection to fully stage patients with small PNETs. Patients with other high-risk factors should also be considered for resection and regional lymphadenectomy.

    View details for DOI 10.1159/000502581

    View details for PubMedID 31401633

  • Adjuvant chemotherapy versus chemoradiation in high-risk pancreatic adenocarcinoma: A propensity score-matched analysis. Cancer medicine Raoof, M., Blakely, A. M., Melstrom, L. G., Lee, B., Warner, S. G., Chung, V., Singh, G., Chen, Y. J., Fong, Y. 2019

    Abstract

    The American Society of Clinical Oncology guidelines recommend adjuvant chemoradiation (ACR) for margin-positive (R1) and/or node-positive (N+) pancreatic cancers. Our goal was to investigate if there is evidence of superiority of adjuvant chemoradiation (ACR) over adjuvant chemotherapy (AC).We utilized data from the National Cancer Database (NCDB) for N+ and/or R1 pancreatic adenocarcinoma patients diagnosed from 2004 to 2012 who underwent ACR or AC. Patients who received neoadjuvant radiation, no adjuvant treatment, or adjuvant radiation alone were excluded. Propensity score nearest-neighbor 1:1 matching (PSM) was performed between ACR and AC groups based on age, sex, race, insurance, year of diagnosis, comorbidities, tumor site and size, T-stage, nodal status, margin status, grade, and treatment facility. Primary outcome was overall survival (OS).A total of 8297 patients were eligible. After PSM, two well-balanced groups of 3244 patients each were analyzed. ACR resulted in superior OS compared with AC alone (Hazard ratio [HR] 0.83, 95% CI 0.79-0.87; median OS 22 vs 19 months, P < .0001). Subset analyses demonstrated OS benefit of ACR compared with AC in N+, R0 patients (HR: 0.82, 95% CI 0.77-0.88; Median OS 24 vs 20 months, P < .001) as well as N+, R1 patients (HR: 0.77, 95% CI 0.68-0.87; Median OS 17 vs 15 months, P < .001); but not in node-negative, R1 patients (HR: 1.12, 95% CI 0.84-1.48; Median OS 18 vs 22 months, P = .63).The addition of radiation to AC was associated with a clinically small but meaningful increase in survival of patients undergoing curative-intent pancreatic resections. This association was not evident in patients with microscopically positive margins but node-negative disease and larger studies will be needed.

    View details for DOI 10.1002/cam4.2491

    View details for PubMedID 31414566

  • Lymphovascular Invasion Is Associated with Lymph Node Involvement in Small Appendiceal Neuroendocrine Tumors. Annals of surgical oncology Blakely, A. M., Raoof, M., Ituarte, P. H., Fong, Y., Singh, G., Lee, B. 2019; 26 (12): 4008?15

    Abstract

    Appendiceal neuroendocrine tumors (NETs) are incidentally found in up to 1% of appendectomy specimens. The association of lymphovascular invasion (LVI) with risk of regional lymph node involvement is unclear.From the National Cancer Database, 2004-2015, this study identified patients who had tumors 2 cm or smaller with one or more lymph nodes (LNs) pathologically evaluated. The histology was defined as typical, goblet cell, or composite NETs. Patient demographics, tumor characteristics, and treatment variables were analyzed.The histologies for the 1767 identified patients were typical (n?=?921, 52.1%), goblet cell (n?=?556, 31.5%), and composite (n?=?290, 16.4%). The tumor grades were low (70.4%), moderate (18.6%), and high (11%). The overall LN positivity was 17%. Of 1052 tumors evaluated, 215 (20.4%) had LVI. Overall survival decreased with node involvement (mean 84 vs. 124 months; p?

    View details for DOI 10.1245/s10434-019-07637-9

    View details for PubMedID 31359272

  • Primary Tumor Sidedness is Predictive of Survival in Colon Cancer Patients Treated with Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy: A US HIPEC Collaborative Study. Annals of surgical oncology Kotha, N. V., Baumgartner, J. M., Veerapong, J., Cloyd, J. M., Ahmed, A., Grotz, T. E., Leiting, J. L., Fournier, K., Lee, A. J., Dineen, S. P., Dessureault, S., Clarke, C., Mogal, H., Zaidi, M. Y., Russell, M. C., Patel, S. H., Sussman, J. J., Dhar, V., Lambert, L. A., Hendrix, R. J., Abbott, D. E., Pokrzywa, C., Lafaro, K., Lee, B., Greer, J. B., Fackche, N., Lowy, A. M., Kelly, K. J. 2019; 26 (7): 2234?40

    Abstract

    The clinical relevance of primary tumor sidedness is not fully understood in colon cancer patients with peritoneal metastasis treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).This was a retrospective cohort study of a multi-institutional database of patients with peritoneal surface malignancy at 12 participating high-volume academic centers from the US HIPEC Collaborative.Overall, 336 patients with colon primary tumors who underwent curative-intent CRS with or without HIPEC were identified; 179 (53.3%) patients had right-sided primary tumors and 157 (46.7%) had left-sided primary tumors. Patients with right-sided tumors were more likely to be older, male, have higher Peritoneal Cancer Index (PCI), and have a perforated primary tumor, but were less likely to have extraperitoneal disease. Patients with complete cytoreduction (CC-0/1) had a median disease-free survival (DFS) of 11.5 months (95% confidence interval [CI] 7.6-15.3) versus 13.1 months (95% CI 9.5-16.8) [p?=?0.158] and median overall survival (OS) of 30 months (95% CI 23.5-36.6) versus 45.4 months (95% CI 35.9-54.8) [p?=?0.028] for right- and left-sided tumors; respectively. Multivariate analysis revealed that right-sided primary tumor was an independent predictor of worse DFS (hazard ratio [HR] 1.75, 95% CI 1.19-2.56; p?=0.004) and OS (HR 1.72, 95% CI 1.09-2.73; p?=?0.020).Right-sided primary tumor was an independent predictor of worse DFS and OS. Relevant clinicopathologic criteria, such as tumor sidedness and PCI, should be considered in patient selection for CRS with or without HIPEC, and guide stratification for clinical trials.

    View details for DOI 10.1245/s10434-019-07373-0

    View details for PubMedID 31016486

  • Lymphovascular Invasion Predicts Lymph Node Involvement in Small (< 2 cm) Appendiceal Neuroendocrine Tumors Blakely, A. M., Raoof, M., Ituarte, P. G., Singh, G., Lee, B. ELSEVIER SCIENCE INC. 2018: E57
  • Selecting incision-dominant cases for robotic liver resection: towards outpatient hepatectomy with rapid recovery HEPATOBILIARY SURGERY AND NUTRITION Melstrom, L. G., Warner, S. G., Woo, Y., Sun, V., Lee, B., Singh, G., Fong, Y. 2018; 7 (2): 77?84

    Abstract

    The premise of minimally invasive surgery (MIS) is to minimize facial and muscle injury in order to enhance recovery from surgery. Robotic MIS surgery for resection of tumors in solid organs is gaining traction, though clear superiority of this approach is lacking and robotic surgery is more expensive. Our philosophy in robotically-assisted hepatectomy has been to employ this approach for cases where location of tumors make difficult a classical laparoscopic approach (superior/posterior tumors), and cases where the incision for an open operation dominates the course of recovery.This is a retrospective review of a prospectively collected database.In this study we report 97 cases of liver resection subjected to the robotic approach, of which 90% were resected robotically. The mean operative time was 186±9 min; mean blood loss was 111±15 mL, and complications occurred in 9%. Two thirds of the patients remained in hospital 3 days or less, including three patients subjected to hemihepatectomy (2 left and 1 right). Fourteen individuals were discharged on the same day. The strongest predictors of long hospital stay (>3 days) were major hepatectomy (P=0.007), complications (P=0.008), and operative time >210 min (P=0.001).With thoughtful case selection, this is a first demonstration that hepatectomy can be conducted as an out-patient or short-stay procedure.

    View details for DOI 10.21037/hbsn.2017.05.05

    View details for Web of Science ID 000430370500001

    View details for PubMedID 29744334

    View details for PubMedCentralID PMC5934136

  • Enhanced Recovery after Surgery for Gastric Cancer Patients Improves Clinical Outcomes at a US Cancer Center. Journal of gastric cancer Desiderio, J., Stewart, C. L., Sun, V., Melstrom, L., Warner, S., Lee, B., Schoellhammer, H. F., Trisal, V., Paz, B., Fong, Y., Woo, Y. 2018; 18 (3): 230?41

    Abstract

    Enhanced recovery after surgery (ERAS) protocols for gastric cancer patients have shown improved outcomes in Asia. However, data on gastric cancer ERAS (GC-ERAS) programs in the United States are sparse. The purpose of this study was to compare perioperative outcomes before and after implementation of an GC-ERAS protocol at a National Comprehensive Cancer Center in the United States.We reviewed medical records of patients surgically treated for gastric cancer with curative intent from January 2012 to October 2016 and compared the GC-ERAS group (November 1, 2015-October 1, 2016) with the historical control (HC) group (January 1, 2012-October 31, 2015). Propensity score matching was used to adjust for age, sex, number of comorbidities, body mass index, stage of disease, and distal versus total gastrectomy.Of a total of 95 identified patients, matching analysis resulted in 20 and 40 patients in the GC-ERAS and HC groups, respectively. Lower rates of nasogastric tube (35% vs. 100%, P<0.001) and intraabdominal drain placement (25% vs. 85%, P<0.001), faster advancement of diet (P<0.001), and shorter length of hospital stay (5.5 vs. 7.8 days, P=0.01) were observed in the GC-ERAS group than in the HC group. The GC-ERAS group showed a trend toward increased use of minimally invasive surgery (P=0.06). There were similar complication and 30-day readmission rates between the two groups (P=0.57 and P=0.66, respectively).The implementation of a GC-ERAS protocol significantly improved perioperative outcomes in a western cancer center. This finding warrants further prospective investigation.

    View details for DOI 10.5230/jgc.2018.18.e24

    View details for PubMedID 30276000

    View details for PubMedCentralID PMC6160527

  • The Comprehensive Complication Index: a New Measure of the Burden of Complications After Hyperthermic Intraperitoneal Chemotherapy. Annals of surgical oncology Dumitra, S., O'Leary, M., Raoof, M., Wakabayashi, M., Dellinger, T. H., Han, E. S., Lee, S. J., Lee, B. 2018; 25 (3): 688?93

    Abstract

    Cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) are complex surgeries with multiple comorbidities. The Clavien-Dindo classification (CDC) is the most commonly used method to report surgical morbidity, but limits it to the highest-grade complication. The Comprehensive Complication Index (CCI) is a score ranging from 0 to 100, calculated using all 30-day complications and their treatment after abdominal surgery. The aim of this study is to assess the CCI's validity in the HIPEC patient population.A review of our institutional cytoreduction database from 2009 to 2015 was undertaken. Patient demographics, pathology, Peritoneal Carcinomatosis Index (PCI), complications and their treatments, and length of stay (LOS) were reviewed. The CCI was calculated for each patient. Linear regression was used to assess whether the CCI and CDC were predictors of LOS.Of 157 patients reviewed, 110 (70.1%) underwent HIPEC. The majority were female (77, 66.9%), and the mean age was 53.7 years. Mean PCI was 13.2 [interquartile range (IQR) 7-18]. Median CDC was grade 2 (IQR 0-2), and only 9.8% had CDC of grade 4 or higher. Mean CCI was 21.4, while the median was 20.9 (IQR 0-30.8). Mean LOS was 16.2 days, while the median was 11 days (IQR 8-15 days). The CCI strongly correlated with LOS with coefficient of 0.46 [95% confidence interval (CI) 0.38-0.54, p = 0.000].The CCI is an adequate tool to capture all complications and their overall burden in patients having undergone HIPEC. This study shows that the CCI can predict LOS and could be used to quantify and compare the burden of multiple complications.

    View details for DOI 10.1245/s10434-017-6157-z

    View details for PubMedID 29260417

  • Resection of the Primary Gastrointestinal Neuroendocrine Tumor Improves Survival with or without Liver Treatment. Annals of surgery Lewis, A., Raoof, M., Ituarte, P. H., Williams, J., Melstrom, L., Li, D., Lee, B., Singh, G. 2018

    Abstract

    The aim of this study was to determine outcomes of primary tumor resection in metastatic neuroendocrine tumors across all primary tumor sites.Primary tumor resection (PTR) may offer a survival benefit in metastatic gastrointestinal neuroendocrine tumors (GI-NETs); however, few studies have examined the effect of primary site and grade on resection and survival.This is a retrospective study of patients with metastatic GI-NETs at presentation between 2005 and 2011 using the California Cancer Registry (CCR) dataset merged with California Office of Statewide Health Planning and Development (OSHPD) inpatient longitudinal database. Primary outcome was overall survival (OS). Univariate and multivariate (MV) analyses were performed using the Pearson Chi-squared tests and Cox proportional hazard, respectively. OS was estimated using the Kaplan-Meier method and log-rank test.A total of 854 patients with GI-NET metastases on presentation underwent 392 PTRs. Liver metastases occurred in 430 patients; 240 received liver treatment(s). PTR improved OS in patients with untreated metastases (median survival 10 vs 38 months, P < 0.001). On MV analysis adjusted for demographics, tumor stage, grade, chemotherapy use, Charlson comorbidity index, primary tumor location, or treatment of liver metastases, PTR with/without liver treatment improved OS in comparison to no treatment [hazard ratio (HR) 0.50, P < 0.001 and 0.39, P < 0.001, respectively]. PTR offered a survival benefit across all grades (low-grade, HR 0.38, P = 0.002 and high-grade, HR 0.62, P = 0.025) CONCLUSION:: PTR in GI-NET is associated with a better survival, with or without liver treatment, irrespective of grade. This study supports the resection of the primary tumor in patients with metastatic GI-NETs, independent of liver treatment.

    View details for DOI 10.1097/SLA.0000000000002809

    View details for PubMedID 29746336

  • A collaborative surgical approach to upper and lower abdominal cytoreductive surgery in ovarian cancer. Journal of surgical oncology Eng, O. S., Raoof, M., Blakely, A. M., Yu, X., Lee, S. J., Han, E. S., Wakabayashi, M. T., Yuh, B., Lee, B., Dellinger, T. H. 2018; 118 (1): 121?26

    Abstract

    Cytoreductive surgery with complete macroscopic resection in patients with ovarian cancer is associated with improved survival. Institutional reports of combined upper and lower abdominal cytoreductive surgery for more advanced disease have described multidisciplinary approaches. We sought to investigate outcomes in patients undergoing cytoreductive surgery in patients with upper and lower abdominal disease at our institution.Patients who underwent cytoreductive surgery for ovarian malignancies from 2008 to 2015 were retrospectively identified from an institutional database. Upper abdominal cytoreduction was defined anatomically as debulking of disease proximal to the ligament of Treitz. Perioperative outcomes were analyzed.A total of 258 operations were performed, the majority for serous ovarian carcinoma (70%). The gynecologic oncologist was the primary surgeon and often assisted by either a surgical oncology fellow and/or attending. In operations with combined upper and lower abdominal cytoreduction, patients were more likely to have an American society of anesthesiologists physical status classification system (ASA) of 3, peritoneal implants, and liver/spleen metastases. Preoperative chemotherapy and optimal cytoreduction were similar between groups. Perioperative morbidity and mortality were not significantly different between groups.A collaborative surgical approach to combined upper and lower abdominal cytoreductive surgery in patients with ovarian cancer should be performed, if needed, to achieve an optimal cytoreduction.

    View details for DOI 10.1002/jso.25120

    View details for PubMedID 29878375

  • Hypothermia Is Associated with Surgical Site Infection in Cytoreductive Surgery with Hyperthermic Intra-Peritoneal Chemotherapy. Surgical infections Eng, O. S., Raoof, M., O'Leary, M. P., Lew, M. W., Wakabayashi, M. T., Paz, I. B., Melstrom, L. G., Lee, B. 2018; 19 (6): 618?21

    Abstract

    Maintenance of peri-operative normothermia remains a global quality metric for hospitals. Hypothermia is associated with surgical site infections (SSIs) in colorectal surgery. Patients undergoing cytoreductive surgery (CRS) with hyperthermic intra-peritoneal chemotherapy (HIPEC) can experience multiple complications post-operatively. We sought to investigate the association of peri-operative hypothermia with SSIs in patients undergoing CRS/HIPEC at our institution.Patients undergoing CRS/HIPEC from 2009-2017 were identified retrospectively from a prospectively collected institutional database. Hypothermia defined as less than 36.0°C in accordance with the Agency for Healthcare Research and Quality metric. Regression analyses were performed with SSIs diagnosed within 30 days post-operatively as the primary outcome.A total of 170 patients were identified, 14 (8.2%) of whom developed an SSI. Patients who developed an SSI experienced lower median temperatures (p?=?0.027) and a greater percentage of operative time in hypothermia (p?=?0.008). On a multivariable analysis adjusting for known risk factors for SSI, the percentage of operative time in hypothermia (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.07, p?=?0.008) was the only parameter associated with SSI within 30 days post-operatively.Hypothermia is associated with the development of SSIs in patients undergoing CRS/HIPEC. Our findings suggest that minimizing peri-operative temperatures to less than 36.0°C may decrease peri-operative SSI in this patient population.

    View details for DOI 10.1089/sur.2018.063

    View details for PubMedID 30044187

  • Robotic total pancreatectomy with splenectomy: technique and outcomes. Surgical endoscopy Konstantinidis, I. T., Jutric, Z., Eng, O. S., Warner, S. G., Melstrom, L. G., Fong, Y., Lee, B., Singh, G. 2018; 32 (8): 3691?96

    Abstract

    Robotic total pancreatectomy (TP) represents a minimally invasive approach to a major intra-abdominal operation. Its utility, technique, and outcomes are evolving.In this video, we describe a systematic approach to a robotic total pancreatectomy performed for multifocal intraductal papillary mucinous neoplasm (IPMN). Additionally, we reviewed the National Cancer Database (NCDB) to examine the outcomes of robotic TP compared to laparoscopic and open TP between 2010 and 2014.The patient is a 61-year-old female who was diagnosed with multifocal IPMN. A total of 6 robotic ports were placed and the da Vinci Xi robotic system was used with the patient supine. The approach entailed as follows: (1) Diagnostic laparoscopy; (2) Entry into the lesser sac; (3) Division of the short gastric vessels; (4) Exposure and dissection of the inferior pancreas border; (5) Dissection and transection of the splenic artery; (6) Mobilization of the pancreas tail/spleen; (7) Exposure of the splenic vein-superior mesenteric vein confluence; (8) Kocher maneuver; (9) Release of the ligament of Treitz and transection of the proximal jejunum; (10) Transection of the distal stomach; (11) Portal lymphadenectomy; (12) Dissection and transection of the gastroduodenal artery; (13) Superior mesenteric vein exposure/dissection of the uncinate process; (14) Hepaticojejunostomy; (15) Cholecystectomy; and (16) Gastrojejunostomy. NCDB database review of 73 patients who underwent robotic TP revealed similar rates of margin negative resections and retrieved lymph nodes between robotic, laparoscopic, and open TP, whereas robotic and laparoscopic TP were associated with shorter in-hospital stay and reduced mortality at 30 and 90 days compared to open TP. Overall median survival of pancreatic adenocarcinoma patients who underwent TP was similar between robotic, laparoscopic, and open approaches.Robotic total pancreatectomy with splenectomy offers a minimally invasive approach to a major abdominal operation and is feasible in a stepwise, reproducible technique. It is associated with improved postoperative outcomes and equivalent oncologic outcomes compared to open TP.

    View details for DOI 10.1007/s00464-017-6003-1

    View details for PubMedID 29273875

    View details for PubMedCentralID PMC6014914

  • Is Fecal Diversion Needed in Pelvic Anastomoses During Hyperthermic Intraperitoneal Chemotherapy (HIPEC)? (vol 24, pg 2122, 2017) ANNALS OF SURGICAL ONCOLOGY Whealon, M. D., Gahagan, J. V., Sujatha-Bhaskar, S., O'Leary, M. P., Selleck, M., Dumitra, S., Lee, B., Senthil, M., Pigazzi, A. 2017; 24: S690

    View details for DOI 10.1245/s10434-017-5893-4

    View details for Web of Science ID 000435688900094

    View details for PubMedID 28547561

  • Efficacy of Self-Expandable Metallic Stents for Colonic and Extracolonic Malignant Obstruction Lin, J. L., David, D., Lee, B. MOSBY-ELSEVIER. 2017: AB401
  • Frailty Correlates with Postoperative Mortality and Major Morbidity After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. Annals of surgical oncology Konstantinidis, I. T., Chouliaras, K., Levine, E. A., Lee, B., Votanopoulos, K. I. 2017; 24 (13): 3825?30

    Abstract

    Frailty is increasingly being recognized as a powerful predictor of postoperative outcomes for cancer patients. This study examined the role of the modified frailty index (MFI) in predicting outcomes for patients undergoing cytoreduction (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC).Data from National Surgical Quality Improvement Program (NSQIP) patients who underwent CRS/HIPEC between 2005 and 2014 were reviewed. The MFI, validated for use in NSQIP, was used to determine correlation between frailty and postoperative outcomes.The analysis included 1171 patients. The patients were divided into three groups: non-frail (MFI 0), mildly frail (MFI 1 or 2), or severely frail (MFI ? 3). More than 90% of patients had an MFI of 0 or 1. The MFI was 0 for 716 patients (61.1%), 1 for 373 patients (31.9%), 2 for 76 patients (6.5%), 3 for 5 patients (0.4%), and 4 for 1 patient (0.1%). Overall, grade 4 Clavien morbidity was observed in 99 patients (8.5%) and mortality in 26 patients (2.2%). For non-frail, mildly frail, and severely frail patients, worsening frailty correlated respectively with increases in grade 4 Clavien morbidity (6.7% vs. 10.9% vs. 33.3%; p = 0.004) and mortality (1.3% vs. 3.3% vs. 33.3%; p < 0.001). In the multivariate analysis, which included age of 70 years or older and albumin level of 3 or lower, frailty was the only factor that correlated with postoperative mortality: non-frail:reference, mildly frail [odds ratio (OR) 2.76, 95% confidence interval (CI) 1.14-6.73; p = 0.025], severely frail (OR 29.1, 95% CI 4-210.87; p = 0.01), age of 70 years or older (OR 1.16, 95% CI 0.34-3.93; p = 0.81), and albumin level of 3 or lower (OR 2.42, 95% CI 0.84-6.98; p = 0.1).Frailty is a strong predictor of major grade 4 morbidity and mortality after CRS/HIPEC. Severe frailty should be a relative contraindication to CRS/HIPEC. Frailty correlates should be a selection factor in the evaluation of all candidates for CRS/HIPEC.

    View details for DOI 10.1245/s10434-017-6111-0

    View details for PubMedID 29019118

  • Association of Fluid Administration With Morbidity in Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy. JAMA surgery Eng, O. S., Dumitra, S., O'Leary, M., Raoof, M., Wakabayashi, M., Dellinger, T. H., Han, E. S., Lee, S. J., Paz, I. B., Lee, B. 2017; 152 (12): 1156?60

    Abstract

    Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal cancers can be associated with significant complications. Randomized trials have demonstrated increased morbidity with liberal fluid regimens in abdominal surgery.To investigate the association of intraoperative fluid administration and morbidity in patients undergoing CRS/HIPEC.A retrospective analysis of information from a prospectively collected institutional database was conducted at a National Cancer Institute-designated comprehensive cancer center. A total of 133 patients from April 15, 2009, to June 23, 2016, with primary or secondary peritoneal cancers were included.Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.Morbidity associated with intraoperative fluid management calculated by the comprehensive complication index, which uses a formula combining all perioperative complications and their severities into a continuous variable from 0 to 100 in each patient.Of the 133 patients identified, 38% and 37% had diagnoses of metastatic appendiceal and colorectal cancers, respectively. Mean age was 54 (interquartile range [IQR], 47-64) years, and mean peritoneal cancer index was 13 (IQR, 7-18). Mitomycin and platinum-based chemotherapeutic agents were used in 96 (72.2%) and 37 (27.8%) of the patients, respectively. Mean intraoperative fluid (IOF) rate was 15.7 (IQR, 11.3-18.7) mL/kg/h. Mean comprehensive complication index (CCI) was 26.0 (IQR, 8.7-36.2). On multivariate analysis, age (coefficient, 0.32; 95% CI, 0.01-0.64; P?=?.04), IOF rate (coefficient, 0.97; 95% CI, 0.19-1.75; P?=?.02), and estimated blood loss (coefficient, 0.02; 95% CI, 0.01-0.03; P?=?.002) were independent predictors of increased CCI. In particular, patients who received greater than the mean IOF rate experienced a 43% increase in the CCI compared with patients who received less than the mean IOF rate (31.5 vs 22.0; P?=?.02).Intraoperative fluid administration is associated with a significant increase in perioperative morbidity in patients undergoing CRS/HIPEC. Fluid administration protocols that include standardized restrictive fluid rates can potentially help to mitigate morbidity in patients undergoing CRS/HIPEC.

    View details for DOI 10.1001/jamasurg.2017.2865

    View details for PubMedID 28832866

    View details for PubMedCentralID PMC5831441

  • Robotic Total Pelvic Exenteration: Video-Illustrated Technique. Annals of surgical oncology Konstantinidis, I. T., Chu, W., Tozzi, F., Lau, C., Wakabayashi, M., Chan, K., Lee, B. 2017; 24 (11): 3422?23

    Abstract

    Robotic-assisted total pelvic exenteration (TPE) can offer a minimally invasive approach to a major multi-organ operation.In this video, we summarize a stepwise approach to robotic TPE in a 70 year-old female Jehovah's witness with a history of cervical cancer post-chemoradiation and radical hysterectomy who experienced local recurrence at the vaginal cuff involving the rectum and bladder.The patient was placed in the lithotomy position. A total of six robotic ports were used and the da Vinci Si robotic system was docked between the legs. We proceeded as follows: (1) the abdomen and pelvis were thoroughly explored for evidence of metastatic disease; (2) the pelvic sidewalls were mobilized and bilateral ureters identified; (3) the mesorectal plane was dissected to the level of the levators; (4) the lateral and anterior pelvic structures were completely mobilized, and parametrial tissues were mobilized to the pelvic wall; (5) the bladder was separated from the pubis symphysis, the space of Retzius entered, and the bladder and proximal urethra freed; (6) a perineal incision was made around the vagina, perineal body, and anus, which were excised; (7) an Alloderm mesh secured the pelvic floor, and an omental J flap was mobilized; and (8) a 6 cm incision was utilized for creation of an ileal conduit and a permanent-end colostomy. Final pathology was consistent with recurrent cervical squamous cell carcinoma invading into the vaginal, bladder, and rectal walls. Surgical margins and seven lymph nodes were negative for carcinoma.Robotic-assisted TPE is technically feasible in a Jehovah's witness under a multidisciplinary surgical team, even in the setting of prior radical hysterectomy and irradiated tissue.

    View details for DOI 10.1245/s10434-017-6036-7

    View details for PubMedID 28808931

  • Mesenteric Lymphadenectomy in Well-Differentiated Appendiceal Neuroendocrine Tumors. Diseases of the colon and rectum Raoof, M., Dumitra, S., O'Leary, M. P., Singh, G., Fong, Y., Lee, B. 2017; 60 (7): 674?81

    Abstract

    Surgical resection is the primary therapy for local and locally advanced appendiceal neuroendocrine tumors. The role of mesenteric lymphadenectomy in these patients is undefined.The purpose of this study was to define the role and prognostic significance of mesenteric lymphadenectomy.This was a retrospective, observational study.A population-based cohort from the National Cancer Institute Surveillance, Epidemiology, and End Results registry (January 1988 to November 2013) was used.Patients with well-differentiated neuroendocrine tumors and nonmixed histologies undergoing surgical resection were included.The risk of lymph node metastases as a function of tumor size and overall survival with respect to lymph node count and tumor size was measured. Lymph node cut-point was determined using the Contal and O'Quigely method.Of the 573 patients who met the inclusion criteria, 64% were women, 79% were white, and 76% were <60 years of age. Seventy percent of the tumors were ?2?cm, and 77% were lymph node negative. Median lymph nodes retrieved were 0 (interquartile range, 0-14). The probability of nodal metastases was 2.7% in tumors ?1.0?cm, 31.0% in tumors 1.1 to 2.0?cm, and 64.0% in tumors >2.0?cm. The probability of a positive lymph node increased with increasing lymph node count up to 26 lymph nodes. An ideal cut-point of 12 lymph nodes was identified by statistical modeling. After adjustment in the multivariable model, the group with 12 or fewer lymph nodes examined had significantly worse overall survival (HR = 4.33 (95% CI, 1.54-12.15); p = 0.005; 5-year survival, 88% versus 96%) than the group with more than 12 lymph nodes examined.Analysis was limited by the variables available in the database.This is the largest study to date that looks at prognostic significance of lymph node count for well-differentiated appendiceal neuroendocrine tumors. Overall survival was worse where 12 or fewer lymph nodes were identified for tumors >1?cm. See Video Abstract at http://links.lww.com/DCR/A352.

    View details for DOI 10.1097/DCR.0000000000000852

    View details for PubMedID 28594716

  • Wireless Monitoring Program of Patient-Centered Outcomes and Recovery Before and After Major Abdominal Cancer Surgery. JAMA surgery Sun, V., Dumitra, S., Ruel, N., Lee, B., Melstrom, L., Melstrom, K., Woo, Y., Sentovich, S., Singh, G., Fong, Y. 2017; 152 (9): 852?59

    Abstract

    A combined subjective and objective wireless monitoring program of patient-centered outcomes can be carried out in patients before and after major abdominal cancer surgery.To conduct a proof-of-concept pilot study of a wireless, patient-centered outcomes monitoring program before and after major abdominal cancer surgery.In this proof-of-concept pilot study, patients wore wristband pedometers and completed online patient-reported outcome surveys (symptoms and quality of life) 3 to 7 days before surgery, during hospitalization, and up to 2 weeks after discharge. Reminders via email were generated for all moderate to severe scores for symptoms and quality of life. Surgery-related data were collected via electronic medical records, and complications were calculated using the Clavien-Dindo classification. The study was carried out in the inpatient and outpatient surgical oncology unit of one National Cancer Institute-designated comprehensive cancer center. Eligible patients were scheduled to undergo curative resection for hepatobiliary and gastrointestinal cancers, were English speaking, and were 18 years or older. Twenty participants were enrolled over 4 months. The study dates were April 1, 2015, to July 31, 2016.Outcomes included adherence to wearing the pedometer, adherence to completing the surveys (MD Anderson Symptom Inventory and EuroQol 5-dimensional descriptive system), and satisfaction with the monitoring program.This study included a final sample of 20 patients (median age, 55.5 years [range, 22-74 years]; 15 [75%] female) with evaluable data. Pedometer adherence (88% [17 of 20] before surgery vs 83% [16 of 20] after discharge) was higher than survey adherence (65% to 75% [13 of 20 and 15 of 20] completed). The median number of daily steps at day 7 was 1689 (19% of daily steps at baseline), which correlated with the Comprehensive Complication Index, for which the median was 15 of 100 (r?=?-0.64, P?

    View details for DOI 10.1001/jamasurg.2017.1519

    View details for PubMedID 28593266

    View details for PubMedCentralID PMC5607084

  • Base Excess as a Predictor of Complications in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. Annals of surgical oncology Eng, O. S., Dumitra, S., O'Leary, M., Wakabayashi, M., Dellinger, T. H., Han, E. S., Lee, S. J., Benjamin Paz, I., Singh, G., Lee, B. 2017; 24 (9): 2707?11

    Abstract

    Base excess is important in assessing metabolic status. Postoperative management in patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies can be a challenge, and we therefore sought to investigate perioperative predictors of overall morbidity in CRS/HIPEC patients at our institution.Patients who underwent CRS/HIPEC from 2012 to 2016 were identified retrospectively from a prospectively collected institutional database. Patient demographics and perioperative variables were obtained and the comprehensive complication index (CCI) was calculated for each patient in order to assess perioperative morbidity. Stepwise linear regression analyses were performed, with CCI as the outcome variable.A total of 72 CRS/HIPEC patients had recorded base excesses in the first 48 h postoperatively. Mean immediate postoperative base excess was -6.0 mmol/L (interquartile range [IQR] -8 to -4.1), mean delta base excess at 48 h was +4.3 mmol/L (IQR +2.1 to +6.2), and mean CCI was 25.2 (IQR 8.7-36.7). On multivariate analysis, delta base excess was the only significant predictor of CCI, demonstrating a protective effect (p = 0.001). In patients who experienced less than the mean delta base excess of +4.3 mmol/L, lower delta base excess was an independent predictor of complications (p < 0.001).Delta base excess is an independent predictor of morbidity in patients undergoing CRS/HIPEC. A delta base excess of greater than +4.3 mmol/L at 48 h may be an appropriate goal for resuscitation of CRS/HIPEC patients in the immediate postoperative period. Standardized protocols to correct the base deficit in CRS/HIPEC patients during the early postoperative period can potentially help mitigate perioperative morbidity.

    View details for DOI 10.1245/s10434-017-5869-4

    View details for PubMedID 28560593

  • Minimally invasive distal pancreatectomy: greatest benefit for the frail. Surgical endoscopy Konstantinidis, I. T., Lewis, A., Lee, B., Warner, S. G., Woo, Y., Singh, G., Fong, Y., Melstrom, L. G. 2017; 31 (12): 5234?40

    Abstract

    The benefits of minimally invasive distal pancreatectomy (MIDP) over open surgery continue to be investigated. Frailty is a known predictor of postoperative outcome. We hypothesized that the benefit of minimally invasive distal pancreatectomy is the greatest for the frailest of patients.Data from the pancreas-targeted National Surgical Quality Improvement Program (NSQIP) database for 2014 were reviewed. A modified frailty index (mFI) with 11 preoperative variables previously validated for use in NSQIP was used to determine the correlation between frailty and postoperative outcomes, including Clavien grade IV complications. Patients were classified into non-frail (mFI = 0) or frail (mIF > 0), in which they were subclassified into mildly frail (mFI 1 or 2) or severely frail (mFI = 3).A total of 1,038 distal pancreatectomies (DP) were included in the analysis, of which 387 were minimally invasive (MIDP: laparoscopic: 285, robotic: 102), 558 open DP (ODP), and 93 MIDP converted to open (MIDPcODP: laparoscopic: 80, robotic: 13). More than 90% of patients had an mFI of 0 or 1 (mFI 0 = 473 (45.6%), 1 = 466 (44.9%), 2 = 94 (9.1%), and 3 = 5 (0.5%), respectively). Overall, 4.6% of patients experienced Clavien grade IV complications and 1.1% a mortality. Non-frail patients experienced a similar rate of grade IV Clavien complications with MIDP vs. ODP vs. MIDPcOP (2.3 vs. 2.3 vs. 4.9%; p = 0.6), whereas frail patients (mFI > 0) had a lower rate of complications with MIDP (2.4 vs. 8.3 vs. 11.5; p = 0.007). Worsening frailty correlated with an increase in complications (non-frail: 2.5%; mildly frail: 6.3%; severely frail: 20%; p = 0.005).MIDP is associated with a lower risk of Clavien grade IV complications compared to ODP for frail patients, especially for benign disease. Thus, minimally invasive approach may mitigate risk in frail patients.

    View details for DOI 10.1007/s00464-017-5593-y

    View details for PubMedID 28493165

    View details for PubMedCentralID PMC5980234

  • Lymphadenectomy with Optimum of 29 Lymph Nodes Retrieved Associated with Improved Survival in Advanced Gastric Cancer: A 25,000-Patient International Database Study. Journal of the American College of Surgeons Woo, Y., Goldner, B., Ituarte, P., Lee, B., Melstrom, L., Son, T., Noh, S. H., Fong, Y., Hyung, W. J. 2017; 224 (4): 546?55

    Abstract

    Gastric adenocarcinoma is an aggressive disease with frequent lymph node (LN) metastases for which lymphadenectomy results in a survival benefit. In the US, the National Comprehensive Cancer Network guidelines recommend D2 lymphadenectomy or a minimum of 15 LNs retrieved. However, retrieval of only 15 LNs is considered by most international guidelines as inadequate. We sought to evaluate the survival benefits associated with a more complete lymphadenectomy.An international database was constructed by combining gastric cancer cases from the Surveillance, Epidemiology, and End Results program database (n = 13,932) and the Yonsei University Gastric Cancer database (n = 11,358) (total n = 25,289). Kaplan-Meier survival analysis was performed along with Joinpoint analysis to obtain the optimal number of LNs to retrieve based on survival. Prognostic significance of number of nodes retrieved was then confirmed with univariate and multivariate analyses.Analysis for both mean and median survival yielded 29 LNs removed as the Joinpoint. This was confirmed with multivariate analysis, where 15 retrieved LNs cutoff fell out of the model and 29 retrieved LNs remained intact, with a hazard ratio of 0.799 (95% CI 0.759 to 0.842; p < 0.001). Stage-stratified Kaplan-Meier analysis for a cutoff point of 29 LNs also demonstrated a statistically significant improvement in survival.Joinpoint analysis has allowed for the creation of a model demonstrating the point at which additional dissection would not provide additional benefit. This large international dataset analysis demonstrates that the maximal survival advantage is seen by performing a lymphadenectomy with a minimum of 29 LNs retrieved.

    View details for DOI 10.1016/j.jamcollsurg.2016.12.015

    View details for PubMedID 28017807

    View details for PubMedCentralID PMC5606192

  • Is Fecal Diversion Needed in Pelvic Anastomoses During Hyperthermic Intraperitoneal Chemotherapy (HIPEC)? Annals of surgical oncology Whealon, M. D., Gahagan, J. V., Sujatha-Bhaskar, S., O'Leary, M. P., Selleck, M., Dumitra, S., Lee, B., Senthil, M., Pigazzi, A. 2017; 24 (8): 2122?28

    Abstract

    The role of fecal diversion with pelvic anastomosis during cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is not well defined.A retrospective review of patients who underwent CRS and HIPEC between 2009 and 2016 was performed to identify those with a pelvic anastomosis (colorectal, ileorectal, or coloanal anastomosis).The study identified 73 patients who underwent CRS and HIPEC at three different institutions between July 2009 and June of 2016. Of these patients, 32 (44%) underwent a primary anastomosis with a diverting ileostomy, whereas 41 (56%) underwent a primary anastomosis without fecal diversion. The anastomotic leak rate for the no-diversion group was 22% compared with 0% for the group with a diverting ileostomy (p < 0.01). The 90-day mortality rate for the no-diversion group was 7.1%. The hospital stay was 14.1 ± 8.0 days in the diversion group compared with 17.9 ± 12.5 days in the no-diversion group (p = 0.12). Of those patients with a diverting ileostomy, 68% (n = 22) had their bowel continuity restored, 18% of which required a laparotomy for reversal. Postoperative complications occurred for 50% of those who required a laparotomy and for 44% of those who did not require a laparotomy (p = 0.84).Diverting ileostomies in patients with a pelvic anastomosis undergoing CRS and HIPEC are associated with a significantly reduced anastomotic leak rate. Reversal of the diverting ileostomy in this patient population required a laparotomy in 18% of the cases and had an associated morbidity rate of 50%.

    View details for DOI 10.1245/s10434-017-5853-z

    View details for PubMedID 28411306

  • Wireless Real-Time Program Successfully Monitors Recovery after Major Abdominal Surgery Dumitra, S., Sun, V., Ruel, N. H., Lee, B., Woo, Y., Melstrom, L. G., Melstrom, K., Sentovich, S., Singh, G., Fong, Y. ELSEVIER SCIENCE INC. 2016: E49
  • Assessment of the Double-Staple Technique for Esophagoenteric Anastomosis in Gastric Cancer Choi, A. H., Arrington, A., Falor, A., Nelson, R. A., Lew, M., Chao, J., Lee, B., Kim, J. SPRINGER. 2016: 688?92

    Abstract

    Reports on outcomes after double-staple technique (DST) for total and proximal gastrectomy are limited, originating mostly from Asian centers. Our objective was to examine anastomotic leak and stricture with DST for esophagoenteric anastomosis in gastric cancer patients.A single institution review was performed for patients who underwent total/proximal gastrectomy with DST between 2006 and 2015. DST was performed using transoral anvil delivery (OrVil) with end-to-end anastomosis. Clinical characteristics and outcomes, including anastomotic leak and stricture, were recorded.Overall, DST was performed in 60 patients [total gastrectomy (81.7%, n?=?49/60), proximal gastrectomy (10.0%, n?=?6/60), and completion gastrectomy (8.3%, n?=?5/60)]. Neoadjuvant chemotherapy was administered to 21 patients (35.0%), and 6 patients (10.0%) received external beam radiation therapy prior to completion gastrectomy. Operative approach was open (51.7%, n?=?31/60), laparoscopic (43.3%, n?=?26/60), or robotic (5.0%, n?=?3/60). Anastomotic leak occurred in 6.7% (n?=?4/60), while stricture independent of leak was identified in 19.0% (n?=?11/58) of patients. Complications occurred in 38.3% (n?=?23/60) of patients, of which 52% were classified as Clavien-Dindo grades III-V complications.In the largest Western series of DST for esophagoenteric anastomoses in gastric cancer surgery, our experience demonstrates that DST is safe and effective with low rates of leak and stricture.

    View details for DOI 10.1007/s11605-016-3087-1

    View details for Web of Science ID 000373158700004

    View details for PubMedID 26831060

    View details for PubMedCentralID PMC4916499

  • Prognostic significance of lymph node sampling in node-negative appendiceal carcinoids. Raoof, M., Dumitra, S., Singh, G., Fong, Y., Lee, B. AMER SOC CLINICAL ONCOLOGY. 2016
  • Hospital Readmission Following Surgery for Gastric Cancer: Frequency, Timing, Etiologies, and Survival JOURNAL OF GASTROINTESTINAL SURGERY Merchant, S. J., Ituarte, P. G., Choi, A., Sun, V., Chao, J., Lee, B., Kim, J. 2015; 19 (10): 1769?81

    Abstract

    Readmission rates after cancer surgery are infrequently reported, and better understanding of the etiologies for readmission is necessary. We sought to investigate the frequency, timing, and etiologies for hospital readmission after surgery for gastric cancer and whether readmission correlates with clinical outcomes.Hospital readmission was examined through linkage of the California Cancer Registry with the Office of Statewide Health Planning and Development database. Patients with gastric adenocarcinoma who had undergone curative intent surgery between 2000 and 2011 were identified. First readmission within 90 days of initial surgery was analyzed with respect to timing (0-30, 31-60, and 61-90 days) and etiology for readmission. Variables associated with readmission and impact on 5-year overall survival (OS) were examined.A total of 8887 (male, n?=?5326; female, n?=?3561) patients underwent curative intent surgery for gastric adenocarcinoma. Within 90 days of initial surgery, 2559 (28.8 %) patients had inpatient hospital readmission. The majority of readmissions occurred in the first 30 days [0-30, n?=?1371 (53.6 %); 31-60, n?=?773 (30.2 %); and 61-90, n?=?415 (16.2 %)]. Readmission vs. no readmission within 90 days correlated with worse 5-year OS in patients with local (51.2 vs. 70.9 %, p?

    View details for DOI 10.1007/s11605-015-2883-3

    View details for Web of Science ID 000361754800006

    View details for PubMedID 26162924

  • Impact of Gastric Cancer Resection on Body Mass Index AMERICAN SURGEON Luu, C., Arrington, A. K., Falor, A., Kim, J., Lee, B., Nelson, R., Singh, G., Kim, J. 2014; 80 (10): 1022?25

    Abstract

    Major gastric resection alters digestive function and may lead to profound weight loss. The objective of our study was to evaluate trends in body weight loss after curative gastrectomy for malignancy. A review of patients who underwent gastrectomy from 1999 to 2012 at two institutions was conducted. Patient demographics and treatment were assessed. Student's t test and analysis of variance were used to compare groups. Of 168 patients, two patients (1.2%) were Stage 0, 73 (43.5%) Stage I, 46 (27.4%) Stage II, 45 (26.8%) Stage III, and two (1.2%) stage unknown. Fifty-eight patients (34.5%) underwent total gastrectomy with Roux-en-Y esophagojejunostomy and 110 patients (65.5%) underwent subtotal gastrectomy. The average per cent decreases in body mass index (BMI) postgastrectomy at one month, six months, 12 months, and 24 months were 7.6, 11.7, 11.5, and 11.1 per cent, respectively (P = 0.003). The decreases in BMI were the same for all time periods whether patients had subtotal or total gastrectomy. Weight loss after gastric cancer resection is an important measure of quality of life. By understanding patterns of weight change after gastrectomy, we can better counsel and prepare our patients for the long-term effects of gastric cancer surgery.

    View details for Web of Science ID 000342277900024

    View details for PubMedID 25264652

  • Incidence of Inflammatory Breast Cancer in Women, 1992-2009, United States ANNALS OF SURGICAL ONCOLOGY Goldner, B., Behrendt, C. E., Schoellhammer, H. F., Lee, B., Chen, S. L. 2014; 21 (4): 1267?70

    Abstract

    The annual incidence of inflammatory breast cancer (IBC) in the United States reportedly increased during the last quarter of the twentieth century. We investigated whether that increase has continued into the twenty-first century.We queried the Surveillance Epidemiology and End Results database for all cases of IBC in women age 20 and older between 1992 and 2009. Cases were breast tumors with at least one of the following codes: extent of disease size 998, extension 70, or ICD-3-O morphology 8530 or 8533. Age-adjusted incidence was also examined.During 1992-2009, the annual incidence of IBC did not increase over time in any age group, nor did it vary significantly from year to year, except between 2003 and 2004, when there was a jump from 1.6 (95 % confidence interval 1.4-1.8) to 3.1 (2.8-3.4) cases per 100,000 women. Similar changes occurred in all age and racial groups before gradually returning to prejump levels. Overall, the incidence of IBC rose steeply with age until reaching a plateau at age 65. The incidence was greatest among black women (3.0; 2.8-3.2), intermediate among white women (2.1; 2.1-2.2), and lowest among Asian women (1.4; 1.3-1.6).The incidence of IBC has remained essentially stable for nearly two decades. A transient jump in 2003-2004 occurred in all age and racial groups, suggesting adjustment to coding changes at that time. Often described as a disease of younger women, IBC in fact disproportionately affects older women. Racial/ethnic variation in the incidence of IBC suggests that dietary, lifestyle, or genetic factors contribute to its pathogenesis.

    View details for DOI 10.1245/s10434-013-3439-y

    View details for Web of Science ID 000334222500033

    View details for PubMedID 24366421

    View details for PubMedCentralID PMC3947773

  • Effectiveness of capecitabine plus oxaliplatin for advanced colon cancer: A public hospital experience Luu, C., Velasquez, J., Kaji, A., Stabile, B. E., Petrie, B. A., Kumar, R., Caton, A., Kim, J., Chen, S. L., Lee, B. AMER SOC CLINICAL ONCOLOGY. 2013
  • Evaluating malignant intraductal papillary mucinous neoplasm: A population-based study Luu, C., Nelson, R. A., Lee, B., Singh, G., Kim, J. AMER SOC CLINICAL ONCOLOGY. 2013
  • A public hospital experience with young gastric cancer patients Goldner, B. S., Velasquez, J., Stabile, B. E., Chen, S. L., Kim, J., Lin, M., Caton, A., Lee, B. AMER SOC CLINICAL ONCOLOGY. 2013
  • Liver Resection Using a Four-Prong Radiofrequency Transection Device Wagman, L. D., Lee, B., Castillo, E., El-Bayar, H., Lai, L. SOUTHEASTERN SURGICAL CONGRESS. 2009: 991?94

    Abstract

    Multiple techniques are available for division of hepatic parenchyma. This is the largest United States report examining the use of the Habib 4X tissue coagulator (AngioDynamics, Queensbury, NY). The objective was to collect standard parameters associated with successful, benchmarked liver surgery outcomes using this new device, and in particular, examine the risk of margin failure. Ninety-four consecutive operations using the Habib 4X were analyzed with special attention to local failure at resection margin, blood loss/transfusion, and operative times. An institutional review board approved protocol allowed collection and analysis of demographic information and outcomes for intraoperative, perioperative, and long-term follow-up. Eighteen patients had biopsy only. Thirty-one had lobar resections and 46 had wedge or segmental resections. There were 30 primary hepatic and 46 metastatic tumor diagnoses. There were a total of 33 (43%) recurrences with a mean time to recurrence of 212 days (range 15-974). Of the 27 intrahepatic recurrences, four (15%) were at the margin. The OR time ranged from 115 to 642 minutes (average 283 min). The average recorded blood loss was 427 mL; 11 patients were transfused (average 0.43 units). The Habib 4X is a safe tool to use when evaluating the parameters of blood loss, transfusion, and margin recurrence.

    View details for Web of Science ID 000270795300028

    View details for PubMedID 19886151

  • Totally Laparoscopic Gastric Resection with Extended Lymphadenectomy for Gastric Adenocarcinoma ANNALS OF SURGICAL ONCOLOGY Guzman, E. A., Pigazzi, A., Lee, B., Soriano, P. A., Nelson, R. A., Paz, I., Trisal, V., Kim, J., Ellenhorn, J. I. 2009; 16 (8): 2218?23

    Abstract

    Laparoscopic gastric resection with extended lymphadenectomy is being evaluated in North America for the surgical treatment of gastric cancer. The aim of this study is to compare short-term postoperative and oncologic outcomes of laparoscopic and open resection for gastric cancer at a single cancer center.The study population consisted of patients with gastric adenocarcinoma who underwent a completely abdominal intervention with curative intent. Laparoscopic and open gastric resections were compared. A totally laparoscopic technique was employed with a robotic extended lymphadenectomy in a subset of patients.A total of 78 consecutive patients were evaluated, including 30 laparoscopic and 48 open procedures. An extended lymphadenectomy was performed in 58 patients and was executed robotically in 16 of these. There was no difference in the mean number of lymph nodes retrieved by laparoscopic or open approach (24 +/- 8 vs. 26 +/- 15, P = .66). Laparoscopic procedures were associated with decreased blood loss (200 vs. 383 mL, P = .0009) and length of stay (7 vs. 10 days, P = .0009), but increased operative time (399 vs. 298 minutes, P < .0001).Completely laparoscopic gastric resection yields similar lymph node numbers compared with open surgery for gastric cancer. It was found to be advantageous in terms of operative blood loss and length of stay. Minimally invasive techniques represent an oncologically adequate alternative for the surgical treatment of gastric adenocarcinoma.

    View details for DOI 10.1245/s10434-009-0508-3

    View details for Web of Science ID 000268101900021

    View details for PubMedID 19444523

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