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Too Big to Fail: Successful Resection of a Large Hepatocellular Carcinoma with Portal Tumor Thrombus. Digestive diseases and sciences Bergquist, J. R., Li, A. Y., Javadi, C. S., Chima, R. S., Frye, J. S., Visser, B. C. 2020
View details for DOI 10.1007/s10620-020-06682-9

View details for PubMedID 33140182
Challenges of Modeling Outcomes for Surgical Infections: A Word of Caution. Surgical infections Grass, F., Storlie, C. B., Mathis, K. L., Bergquist, J. R., Asai, S., Boughey, J. C., Habermann, E. B., Etzioni, D. A., Cima, R. R. 2020
Abstract

Background: We developed a novel analytic tool for colorectal deep organ/space surgical site infections (C-OSI) prediction utilizing both institutional and extra-institutional American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data. Methods: Elective colorectal resections (2006-2014) were included. The primary end point was C-OSI rate. A Bayesian-Probit regression model with multiple imputation (BPMI) via Dirichlet process handled missing data. The baseline model for comparison was a multivariable logistic regression model (generalized linear model; GLM) with indicator parameters for missing data and stepwise variable selection. Out-of-sample performance was evaluated with receiver operating characteristic (ROC) analysis of 10-fold cross-validated samples. Results: Among 2,376 resections, C-OSI rate was 4.6% (n=108). The BPMI model identified (n=57; 56% sensitivity) of these patients, when set at a threshold leading to 80% specificity (approximately a 20% false alarm rate). The BPMI model produced an area under the curve (AUC)=0.78 via 10-fold cross- validation demonstrating high predictive accuracy. In contrast, the traditional GLM approach produced an AUC=0.71 and a corresponding sensitivity of 0.47 at 80% specificity, both of which were statstically significant differences. In addition, when the model was built utilizing extra-institutional data via inclusion of all (non-Mayo Clinic) patients in ACS-NSQIP, C-OSI prediction was less accurate with AUC=0.74 and sensitivity of 0.47 (i.e., a 19% relative performance decrease) when applied to patients at our institution. Conclusions: Although the statistical methodology associated with the BPMI model provides advantages over conventional handling of missing data, the tool should be built with data specific to the individual institution to optimize performance.

View details for DOI 10.1089/sur.2020.208

View details for PubMedID 33085571
Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients BMC SURGERY Driedger, M. R., Puig, C. A., Thiels, C. A., Bergquist, J. R., Ubl, D. S., Habermann, E. B., Grotz, T. E., Smoot, R. L., Nagorney, D. M., Cleary, S. P., Kendrick, M. L., Truty, M. J. 2020; 20 (1): 169
Abstract

While emergent pancreatic resection for trauma has been previously described, no large contemporary investigations into the frequency, indications, and outcomes of emergent pancreatectomy (EP) secondary to complications of neoplastic disease exist. Modern perioperative outcomes data are currently unknown.ACS-NSQIP was reviewed for all non-traumatic pancreatic resections (DP - distal pancreatectomy, PD - pancreaticoduodenectomy, or TP- total pancreatectomy) in patients with pancreatico-biliary or duodenal-ampullary neoplasms from 2005 to 2013. Patients treated for complications of pancreatitis were specifically excluded. Emergent operation was defined as NSQIP criteria for emergent case and one of the following: ASA Class 5, preoperative ventilator dependency, preoperative SIRS, sepsis, or septic shock, or requirement of >?4?units RBCs in 72?h prior to resection. Chi-square tests, Fisher's exact tests were performed to compare postoperative outcomes between emergent and elective cases as well as between pancreatectomy types.Of 21,452 patients who underwent pancreatectomy for neoplastic indications, we identified 534 (2.5%) patients who underwent emergent resection. Preoperative systemic sepsis (66.3%) and bleeding (17.9%) were most common indications for emergent operation. PD was performed in 409 (77%) patients, DP in 115 (21%), and TP in 10 (2%) patients. Overall major morbidity was significantly higher (46.1% vs. 25.6%, p?
View details for DOI 10.1186/s12893-020-00822-8

View details for Web of Science ID 000556311300001

View details for PubMedID 32718311

View details for PubMedCentralID PMC7385869
Questionable Survival Benefit of Aspirin Use in Patients With Biliary Tract Cancer. JAMA oncology Bergquist, J. R., Shariq, O. A., Visser, B. C. 2020
View details for DOI 10.1001/jamaoncol.2020.0122

View details for PubMedID 32191269
Biliary tract cancer patient-derived xenografts: Surgeon impact on individualized medicine. JHEP reports : innovation in hepatology Leiting, J. L., Murphy, S. J., Bergquist, J. R., Hernandez, M. C., Ivanics, T., Abdelrahman, A. M., Yang, L., Lynch, I., Smadbeck, J. B., Cleary, S. P., Nagorney, D. M., Torbenson, M. S., Graham, R. P., Roberts, L. R., Gores, G. J., Smoot, R. L., Truty, M. J. 2020; 2 (2): 100068
Abstract

Biliary tract tumors are uncommon but highly aggressive malignancies with poor survival outcomes. Due to their low incidence, research into effective therapeutics has been limited. Novel research platforms for pre-clinical studies are desperately needed. We sought to develop a patient-derived biliary tract cancer xenograft catalog.With appropriate consent and approval, surplus malignant tissues were obtained from surgical resection or radiographic biopsy and implanted into immunocompromised mice. Mice were monitored for xenograft growth. Established xenografts were verified by a hepatobiliary pathologist. Xenograft characteristics were correlated with original patient/tumor characteristics and oncologic outcomes. A subset of xenografts were then genomically characterized using Mate Pair sequencing (MPseq).Between October 2013 and January 2018, 87 patients with histologically confirmed biliary tract carcinomas were enrolled. Of the 87 patients, 47 validated PDX models were successfully generated. The majority of the PDX models were created from surgical resection specimens (n�= 44, 94%), which were more likely to successfully engraft when compared to radiologic biopsies (p�= 0.03). Histologic recapitulation of original patient tumor morphology was observed in all xenografts. Successful engraftment was an independent predictor for worse recurrence-free survival. MPseq showed genetically diverse tumors with frequent alterations of CDKN2A, SMAD4, NRG1, TP53. Sequencing also identified worse survival in patients with tumors containing tetraploid genomes.This is the largest series of biliary tract cancer xenografts reported to date. Histologic and genomic analysis of patient-derived xenografts demonstrates accurate recapitulation of original tumor morphology with direct correlations to patient outcomes. Successful development of biliary cancer tumografts is feasible and may be used to direct subsequent therapy in high recurrence risk patients.Patient biliary tract tumors grown in immunocompromised mice are an invaluable resource in the treatment of biliary tract cancers. They can be used to guide individualized cancer treatment in high-risk patients.

View details for DOI 10.1016/j.jhepr.2020.100068

View details for PubMedID 32181445

View details for PubMedCentralID PMC7066236
Laparoscopic hepatic lobectomy for symptomatic polycystic liver disease. HPB : the official journal of the International Hepato Pancreato Biliary Association Li, A. Y., Bergquist, J. R., August, A. T., Dua, M. M., Poultsides, G. A., Visser, B. C. 2020
Abstract

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

View details for DOI 10.1016/j.hpb.2020.04.010

View details for PubMedID 32451237
Nearing the Summit: Associating Liver Partitioning and Portal Ligation for Staged Hepatectomy (ALPPS) in Progressive Carcinoid Disease. Digestive diseases and sciences Bergquist, J. R., Li, A. Y., Chang, E. M., Scott, G. D., Dua, M. M., Visser, B. C. 2020
View details for DOI 10.1007/s10620-020-06257-8

View details for PubMedID 32307614
Novel staging system using carbohydrate antigen (CA) 19-9 in extra-hepatic cholangiocarcinoma and its implications on overall survival. European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology Tella, S. H., Kommalapati, A., Yadav, S., Bergquist, J. R., Goyal, G., Durgin, L., Borad, M., Cleary, S. P., Truty, M. J., Mahipal, A. 2020; 46 (5): 789?95
Abstract

CA19-9 elevation has shown to be associated with poor prognosis in extrahepatic cholangiocarcinoma (ECCA). However, the role of CA19-9 in staging of ECCA has not been evaluated. We hypothesized that CA19-9 elevation is a marker of aggressive biology in ECCA and that inclusion of CA19-9 in the staging system may improve overall survival (OS) discrimination.Patients with ECCA whose CA19-9 levels, irrespective of surgical status, were reported to the National Cancer Database (2004-2015) were included. The patients were classified based on their CA19-9 levels and a new staging system was proposed. Net reclassification improvement (NRI) model was used to assess the predictive improvement in the proposed survival model as compared to AJCC-TNM staging.Of the 2100 patients included in the study, 626 (32%) and 1474 (68%) had normal and elevated CA19-9 levels (>38 U/ml), respectively. Median OS was lower among patients with elevated CA19-9 level compared to those with CA19-9 level ?38 U/ml (8.5 vs 16 months, p�<�0.01). On multivariate analysis, CA19-9 elevation independently predicted poor prognosis [HR:1.72 (1.46-2.02); p�<�0.01] with similar impact as node-positivity, positive resection margins and non-receipt of chemotherapy. We developed a new staging system by incorporating CA19-9 into the 7th edition AJCC TNM staging system. NRI of 46% (95%CI: 39-57%) indicates that the new staging system is substantially effective at re-classifying events at 12 months as compared to AJCC 7th edition.Elevated CA19-9 was found to be an independent risk factor for mortality in ECCA and its inclusion in the proposed staging system improved OS discrimination.

View details for DOI 10.1016/j.ejso.2020.01.016

View details for PubMedID 31954549
Early-onset gastric cancer is a distinct disease with worrisome trends and oncogenic features. Surgery Bergquist, J. R., Leiting, J. L., Habermann, E. B., Cleary, S. P., Kendrick, M. L., Smoot, R. L., Nagorney, D. M., Truty, M. J., Grotz, T. E. 2019; 166 (4): 547?55
Abstract

Overall the incidence of gastric cancer is declining in the United States; however, the incidence of early-onset gastric cancer is increasing. We sought to elucidate clinical and genomic characteristics and risk factors for early-onset gastric cancer compared with late-onset gastric cancer.We utilized the Surveillance, Epidemiology, and End Results database (1973-2015), the Behavioral Risk Factor Surveillance Survey, and The Cancer Genome Atlas to characterize early-onset gastric cancer.The incidence of early-onset gastric cancer increased during the study period and now comprises >30% of all gastric cancer in the United States. Early-onset gastric cancer was associated with higher grade (55.2 vs 46.9%), signet-ring cells (19.0 vs 10.4%), diffuse histology (25.7 vs 15.0%), and metastatic disease (49.5 vs 40.9%, all P < .01) compared with late-onset gastric cancer. Early-onset gastric cancer was more likely to be Epstein-Barr virus (7.7 vs 5.1%) or genomically stable (22.5 vs 8.1%) subtype, whereas late-onset gastric cancer was more likely to be microsatellite instability subtype (18.6 vs 5.6%; all P < .01). Risk factors for gastric cancer were less correlated with early-onset gastric cancer compared with late-onset gastric cancer.The incidence of early-onset gastric cancer has been steadily increasing in the United States, comprising >30% of new gastric cancer cases today. Early-onset gastric cancer is genetically and clinically distinct from traditional gastric cancer. Additional investigations are warranted to better understand this alarming phenomenon.

View details for DOI 10.1016/j.surg.2019.04.036

View details for PubMedID 31331685
Successful Secondary Engraftment of Pancreatic Ductal Adenocarcinoma and Cholangiocarcinoma Patient-Derived Xenografts After Previous Failed Primary Engraftment. Translational oncology Hernandez, M. C., Yang, L., Leiting, J. L., Sugihara, T., Bergquist, J. R., Ivanics, T., Graham, R., Truty, M. J. 2019; 12 (1): 69?75
Abstract

Patient-derived xenografts (PDX) provide histologically accurate cancer models that recapitulate patient malignant phenotype and allow for highly correlative oncologic in-vivo downstream translational studies. Primary PDX engraftment failure has significant negative consequences on programmatic efficiency and resource utilization and is due to either no tumor growth or development of lymphoproliferative tumors. We aimed to determine if secondary engraftment of previously cryopreserved patient tumor tissues would allow salvage of PDX models that failed previous primary engraftment and increase overall engraftment efficiency.Patient hepatobiliary and pancreatic cancers that failed primary engraftment were identified. Previously cryopreserved primary patient cancerous tissues were implanted into immunodeficient mice (NOD/SCID). Mice were monitored, growth metrics calculated, and secondary engraftment outcomes were recorded. Established PDX were verified and compared to original patient tissue through multiple generations by a GI pathologist.We identified 55 patient tumors that previously failed primary engraftment: no tumor growth (n?=?46, 84%) or lymphoproliferative tumor (LT) (n?=?9, 16%). After secondary implantation using cryopreserved patient tissues, 29 new histologically validated PDX models were generated with an overall secondary engraftment rate of 53% for all tumor types with greatest yield in pancreatic and biliary tract cancers. Of the secondary engraftment failures (n?=?26), 21 (38%) were due to no growth and 5 (9%) developed LT.Secondary PDX engraftment using cryopreserved primary cancerous is feasible after previous failed engraftment attempts and can result in a 50% increase in overall engraftment efficiency with decreases in LT formation. This technique allows for salvage of critical patient PDX models that would otherwise not exist.Patient-derived xenografts have many important translational applications however can be limited by engraftment failure. We demonstrate optimized methodology utilizing cryopreservation of primary tumor tissue that allows for subsequent successful secondary engraftment and creation of PDX models that failed previous primary engraftment and allowed salvage of patient PDX models that would otherwise not exist.

View details for DOI 10.1016/j.tranon.2018.09.008

View details for PubMedID 30273859

View details for PubMedCentralID PMC6170258
3D printed modeling contributes to reconstruction of complex chest wall instability. Trauma case reports Bergquist, J. R., Morris, J. M., Matsumoto, J. M., Schiller, H. J., Kim, B. D. 2019; 22: 100218
Abstract

Three-dimensional printed models are increasingly used in many fields including medicine and surgery, but their use in the planning and execution of complex chest wall reconstruction has not been adequately described. In cases of non-union or prior attempts at chest wall reconstruction which have failed, there can be substantial deviations from expected chest wall anatomy. We report a novel technique for pre-operative planning and surgical execution of complex chest wall reconstruction, assisted by 3D printing. Our objective was to utilize 3-D volumetric modeling coupled with 3-D printing to produce patient-specific models for chest wall reconstruction in complex cases.Soft tissue reconstruction 0.75?mm slice thickness computed tomography (CT) imaging data was loaded into medical CAD software for segmentation. Lung, muscle, foreign bodies, and bony structureswere separated due to the differences in density between them. The 3D volumetric mesh was then quality checked and stereolithography files (STL) were made which were able to be utilized by the 3D printer. The STL files were exported to a Objet 500 material jetting printer that utilized several UV light cured photopolymers.As an example case, we discuss a 55?year old male who underwent resuscitative thoracotomy. In the early post-operative period, he developed a pulmonary hernia in the 6th intercostal space, repaired with wire cerclage reapproximation of ribs. He developed a symptomatic mobile chest wall at the site of prior repair with additional concern for dissociated anterior cartilage. In preparation for operative repair, a 3D printed model was created, demonstrating fractured cartilage anteriorly as well a saw effect through the six and seventh ribs. An additional model was created using the normal ribs from the right side in mirror image reflection to quantify the degree and precise geometry of mal-alignment to the left chest. These models were then utilized to determine the operative approach via a thoracotomy incision to remove the cerclage wires, followed by parasternal incision, reduction and plating of the sternocostal non-union bursa Rib non-unions were plate stabilized. Repeat imaging in follow-up has demonstrated continued appropriate alignment and the patient reported improvement in his symptoms.At present, the cost of 3-D printing remains substantial, but given the improved planning in complex cases, this cost may be recaptured in the reduction of operative time and improved outcomes with reduced re-operation rates. We believe that the early adoption of this technology by surgeons can help improve surgical quality and provide enhanced individualized patient care. These patient-specific models facilitate identification of features which are often not detected with standard 3-D reconstructed CT rendering. Centers should pursue the integration of 3-D printed models into their practice and active collaborations between surgeons and modeling experts should be sought at every available opportunity.

View details for DOI 10.1016/j.tcr.2019.100218

View details for PubMedID 31249855

View details for PubMedCentralID PMC6584793
Survival and prognostic factors in patients with pancreatic squamous cell carcinoma. European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology Tella, S. H., Kommalapati, A., Yadav, S., Bergquist, J. R., Truty, M. J., Durgin, L., Ma, W. W., Cleary, S. P., McWilliams, R. R., Mahipal, A. 2019; 45 (9): 1700?1705
Abstract

Squamous cell carcinoma (SCC) of pancreas is rare entity with poorly defined prognostic factors and therapeutic outcomes. We sought to determine the overall survival (OS) and prognostic factors of patients with pancreatic SCC using National Cancer Database (NCDB) (2004-15).Kaplan-Meier method and log-rank test were used to perform OS analysis. Propensity-matched analysis was used to compare the OS of pancreatic SCC and adenocarcinoma.Of the 515 cases included in our analysis, 46% were female. Approximately half of the cohort (48%) received chemotherapy or radiation therapy or both. Twenty six percent (33/125) of stage I and II disease (localized disease), 11% (8/72) of stage III, and 2% (6/318) of stage IV disease underwent surgical resection of the primary tumor. Median OS for the entire cohort was 4 months and was significantly higher in patients who underwent surgical resection of the primary tumor (17 vs 4 months, p?70 years) and stage of the disease at presentation (p?
View details for DOI 10.1016/j.ejso.2019.05.011

View details for PubMedID 31118133
Rituximab Decreases Lymphoproliferative Tumor Formation in Hepatopancreaticobiliary and Gastrointestinal Cancer Patient-Derived Xenografts. Scientific reports Leiting, J. L., Hernandez, M. C., Yang, L., Bergquist, J. R., Ivanics, T., Graham, R. P., Truty, M. J. 2019; 9 (1): 5901
Abstract

High engraftment rates are critical to any patient-derived xenograft (PDX) program and the loss of PDX models due to the development of lymphoproliferative tumors (LTs) is costly and inefficient. We hypothesized that routine injection of rituximab, an anti-CD20 antibody, at the time of implantation would reduce the incidence of LTs. Rituximab injection was added to the standard PDX engraftment protocol. Univariate analysis and multivariate logistic regression were used to determine the significance of various factors. A total of 811 generations of PDX were implanted with 406 receiving rituximab with implantation. On multivariable analysis, rituximab was an independent factor for decreased LT formation across the entire cohort (OR 0.465, 95% CI 0.271-0.797, p?=?0.005). Hepatocellular carcinomas (OR 0.319, 95% CI 0.107-0.949, p?=?0.040) and cholangiocarcinomas (OR 0.185, 95% CI 0.049-0.696, p?=?0.113) were the specific malignant histologic subtypes that demonstrated the greatest benefit. The frequency of LTs decreased across the entire cohort with rituximab administration and PDX tumors that are traditionally associated with higher rates of LT formation, HCCs and CCAs, appear to benefit the most from rituximab treatment. Routine use of rituximab at the time of tumor implantation may have significant programmatic benefits for laboratories that utilize PDX models.

View details for DOI 10.1038/s41598-019-42470-w

View details for PubMedID 30976061

View details for PubMedCentralID PMC6459856
Patient-Derived Xenografts Can Be Reliably Generated from Patient Clinical Biopsy Specimens. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Hernandez, M. C., Bergquist, J. R., Leiting, J. L., Ivanics, T., Yang, L., Smoot, R. L., Nagorney, D. M., Truty, M. J. 2019; 23 (4): 818?24
Abstract

Patient-derived xenografts (PDX) are clinically relevant human cancer models that can be used to guide individualized medicine. We aimed to generate PDX models from clinically obtained biopsy specimens (surgical or image-guided) hypothesizing that low volume biopsy specimens could provide sufficient viable tissue to successfully engraft PDX models from patients with unresectable or metastatic disease.We maintain a prospective high volume gastrointestinal malignancy PDX program. With informed consent and institutional approval, biopsy specimens (surgical or image-guided) were obtained from patients with unresectable or metastatic tumors: pancreatic adenocarcinoma (PDAC), cholangiocarcinoma, gastric and gallbladder carcinoma. Biopsies were implanted into immunodeficient mice. Tumor growth was monitored, viable tumor was passed into subsequent generations, and histopathology was confirmed.In this study, biopsy specimens from 29 patients were used for PDX engraftment. Successful PDX engraftment was variable with highest engraftment rates in gastric and gallbladder carcinoma specimens (100%) compared to engraftment rates of 33% and 29% in PDAC and cholangiocarcinoma respectively. PDX models created from metastasis biopsies compared to unresectable primary tumor tissue demonstrated higher engraftment rates (69% versus 15.4%, p?=?0.001). PDX models demonstrated higher engraftment rates when biopsies were obtained during surgical operations (n?=?15) compared to image-guided (n?=?14) (73% versus 14%, p?=?0.003). Patient age, pretreatment status, or ischemic time was not different between biopsy methods.PDX models can be successfully created from clinical biopsy specimens in patients with metastatic or unresectable GI cancers. The use of clinical biopsy specimens for PDX engraftment can expand the repertoire of stage-specific PDX models for downstream basic/translational research.

View details for DOI 10.1007/s11605-019-04109-z

View details for PubMedID 30756315
Surgery and chemotherapy are associated with improved overall survival in anal adenocarcinoma: results of a national cohort study. International journal of colorectal disease McKenna, N. P., Bergquist, J. R., Habermann, E. B., Chua, H. K., Kelley, S. R., Mathis, K. L. 2019; 34 (4): 607?12
Abstract

Anal adenocarcinoma (AAC) is a rare disease with treatment protocols that mimic both that of rectal adenocarcinoma (RAC) and anal squamous cell carcinoma (ASCC). Due to its rarity, data regarding outcomes are lacking. We sought to determine outcomes of patients with AAC compared to RAC and ASCC and to evaluate risk factors for mortality in AAC.The United States' National Cancer Database was queried for all adult patients presenting with nonmetastatic AAC, RAC, or ASCC from 2003 to 2011. The primary outcome was overall survival. Intergroup univariate comparisons, unadjusted Kaplan-Meier, and multivariable Cox proportional hazards modeling were used to compare outcomes between AAC, RAC, and ASCC and to identify factors associated with survival within AAC.The query identified 129,153 patients (N?=?2117 AAC, 19,427 ASC, 107,609 RAC). AAC patients were less likely than RAC patients to have surgery (72.5 vs. 87.1%), and also less likely to receive chemotherapy (54.7% vs. 96.1%) and radiation (58.2% vs. 74.1%) than patients with ASCC (all p??120�months for ASCC. On multivariable analysis, independent treatment-related predictors of decreased mortality hazard in AAC included proctectomy (hazard ratio [HR], 0.66) and chemotherapy (HR, 0.60) (both p?
View details for DOI 10.1007/s00384-018-03232-8

View details for PubMedID 30635718
Radiation Therapy for Retroperitoneal Sarcomas: Influences of Histology, Grade, and Size. Sarcoma Leiting, J. L., Bergquist, J. R., Hernandez, M. C., Merrell, K. W., Folpe, A. L., Robinson, S. I., Nagorney, D. M., Truty, M. J., Grotz, T. E. 2018; 2018: 7972389
Abstract

Perioperative radiation therapy (RT) has been associated with reduced local recurrence in patients with retroperitoneal sarcomas (RPS); however, selection criteria remain unclear. We hypothesized that perioperative RT would improve survival in patients with RPS and would be associated with pathological factors. The National Cancer Database (NCDB) from 2004 to 2012 was reviewed for patients with nonmetastatic RPS undergoing curative intent resection. Tumor size was dichotomized at 15?cm based on 8th edition American Joint Committee on Cancer (AJCC) staging. Patients with the highest comorbidity score were excluded. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards modeling analyzed overall survival (OS). Multivariable logistic regression modeled margin positivity. A total of 2,264 patients were included; 727 patients (32.1%) had perioperative radiation in whom 203 (9.0%) had radiation preoperatively. Median (IQR) RPS size was 17.5 [11.0-27.0] cm. Histopathology was high grade in 1048 patients (43.7%). Multivariable analysis revealed that perioperative radiation was independently associated with decreased mortality (HR 0.72, 95% confidence intervals (CIs) 0.62-0.84, p < 0.001), and preoperative RT was associated with reduced margin positivity (HR 0.72, 95% CI 0.53-0.97, p=0.032). Stratified survival analysis showed that radiation was associated with prolonged median OS for RPS that were high-grade (64.3 vs. 43.6 months, p < 0.001), less than 15?cm (104.1 vs. 84.2 months, p=0.007), and leiomyosarcomatous (104.8 vs. 61.8 months, p < 0.001). Perioperative radiation is independently associated with decreased mortality in patients with high-grade, less than 15?cm, and leiomyosarcomatous tumors. Preoperative radiation is independently associated with margin-negative resection. These data support the selective use of perioperative radiation in the multidisciplinary management of RPS.

View details for DOI 10.1155/2018/7972389

View details for PubMedID 30631245

View details for PubMedCentralID PMC6304833
Greater Mortality After Emergency Laparotomy in the United Kingdom Compared With United States: A Window Into the Quality of Acute Care Surgery in the United States. Annals of surgery Bergquist, J. R., Thiels, C. A., Hyder, J. A., Zielinski, M. D. 2018; 267 (4): e76?e78
View details for DOI 10.1097/SLA.0000000000002156

View details for PubMedID 28121678
Early Diuresis After Colon and Rectal Surgery Does Not Reduce Length of Hospital Stay: Results of a Randomized Trial. Diseases of the colon and rectum Danelich, I. M., Bergquist, J. R., Bergquist, W. J., Osborn, J. L., Wright, S. S., Tefft, B. J., Sturm, A. W., Langworthy, D. R., Mandrekar, J., Devine, R. M., Kelley, S. R., Mathis, K. L., Pemberton, J. H., Jacob, A. K., Larson, D. W. 2018; 61 (10): 1187?95
Abstract

Excessive perioperative fluid administration likely increases postoperative cardiovascular, infectious, and GI complications. Early administration of diuretics after elective surgery facilitates rapid mobilization of excess fluid, potentially leading to decreased bowel edema, more rapid return of bowel function, and reduced length of hospital stay.This study aimed to evaluate the benefit of early diuresis after elective colon and rectal surgery in the setting of an enhanced recovery after surgery practice.This was a prospective study.The study was conducted at a quaternary referral center.A randomized, open-label, parallel-group trial was conducted in patients undergoing elective colon and rectal surgery at a single quaternary referral center.The primary intervention was administration of intravenous furosemide plus enhanced recovery after surgery on postoperative day 1 and 2 versus enhanced recovery after surgery alone.The primary outcome was length of hospital stay. Secondary outcomes included 30-day readmission rate, time to stool output during hospitalization after surgery, and incidence of various complications within the first 48 hours of hospital stay.In total, 123 patients were randomly assigned to receive either furosemide plus enhanced recovery after surgery (n = 62) or enhanced recovery after surgery alone (n = 61). Groups were evenly matched at baseline. At interim analysis, length of hospital stay was not superior in the intervention group (80.6 vs 99.6 hours, p = 0.564). No significant difference was identified in the rates of nasogastric tube replacement (1.6% vs 9.7%, p = 0.125). Time to return of bowel function was significantly longer in the intervention group (45.4 vs 48.8 hours, p = 0.048). The decision was made to end the study early because the conditional power of the study favored futility.This was a single-center study.Early administration of furosemide does not significantly reduce the length of hospital stay after elective colon and rectal surgery in the setting of enhanced recovery after surgery practice. See Video Abstract at http://links.lww.com/DCR/A714.

View details for DOI 10.1097/DCR.0000000000001183

View details for PubMedID 30192327
Patient-derived xenograft cryopreservation and reanimation outcomes are dependent on cryoprotectant type. Laboratory investigation; a journal of technical methods and pathology Ivanics, T., Bergquist, J. R., Liu, G., Kim, M. P., Kang, Y., Katz, M. H., Perez, M. V., Thomas, R. M., Fleming, J. B., Truty, M. J. 2018; 98 (7): 947?56
Abstract

Patient-derived xenografts (PDX) are being increasingly utilized in preclinical oncologic research. Maintaining large colonies of early generation tumor-bearing mice is impractical and cost-prohibitive. Optimal methods for efficient long-term cryopreservation and subsequent reanimation of PDX tumors are critical to any viable PDX program. We sought to compare the performance of "Standard" and "Specialized" cryoprotectant media on various cryopreservation and reanimation outcomes in PDX tumors. Standard (10% DMSO media) and Specialized (Cryostor�) media were compared between overall and matched PDX tumors. Primary outcome was reanimation engraftment efficiency (REE). Secondary outcomes included time to tumor formation (TTF), time to harvest (TTH), and potential loss of unique PDX lines. Overall 57 unique PDX tumors underwent 484 reanimation engraftment attempts after previous cryopreservation. There were 10 unique PDX tumors cryopreserved with Standard (71 attempts), 40 with Specialized (272 attempts), and 7 with both (141 attempts). Median frozen time of reanimated tumors was 29 weeks (max. 177). Tumor pathology, original primary PDX growth rates, frozen storage times, and number of implantations per PDX model were similar between cryoprotectant groups. Specialized media resulted in superior REE (overall: 82 vs. 39%, p?52 weeks cryostorage: 59 vs. 9%, p?
View details for DOI 10.1038/s41374-018-0042-7

View details for PubMedID 29520054

View details for PubMedCentralID PMC6072591
Adjuvant systemic therapy after resection of node positive gallbladder cancer: Time for a well-designed trial? (Results of a US-national retrospective cohort study). International journal of surgery (London, England) Bergquist, J. R., Shah, H. N., Habermann, E. B., Hernandez, M. C., Ivanics, T., Kendrick, M. L., Smoot, R. L., Nagorney, D. M., Borad, M. J., McWilliams, R. R., Truty, M. J. 2018; 52: 171?79
Abstract

Ideal oncologic management of gallbladder carcinoma (GBCA) after complete surgical resection is unclear. We sought to define benefit of post-resection adjuvant systemic chemotherapy alone in T2 or greater gallbladder carcinoma utilising a large national dataset.The National Cancer Data Base (NCDB) 2004-2012 cohort was retrospectively reviewed for patients with GBCA (T2+) undergoing curative-intent resection and surviving at least 6 weeks. Univariate group comparisons, unadjusted Kaplan-Meier and adjusted Cox proportional hazards analyzed overall survival.4373 patients were included (N?=?2479 T2, N?=?1894 T3/4). Overall, 22.1% of patients received adjuvant chemotherapy. Use of multi-agent chemotherapy increased during the study period. Patients receiving adjuvant therapy were younger, had fewer comorbidities, more often node-positive and more likely R1-margins than those receiving surgery alone. Unadjusted overall survival was improved in all patients with node-positive disease as well as for those with inadequate nodal staging. The benefit of chemotherapy persisted after adjustment for patient and tumor factors.Adjuvant systemic chemotherapy is associated with survival benefit in patients with T2 or greater GBCA with node positive disease. We recommend a multidisciplinary approach in these patients as less than 1-in-4 of them currently receive adjuvant chemotherapy. Future clinical trials should address adjuvant chemotherapy in node positive GBCA.

View details for DOI 10.1016/j.ijsu.2018.02.052

View details for PubMedID 29496648
Medical Malpractice Lawsuits Involving Surgical Residents. JAMA surgery Thiels, C. A., Choudhry, A. J., Ray-Zack, M. D., Lindor, R. A., Bergquist, J. R., Habermann, E. B., Zielinski, M. D. 2018; 153 (1): 8?13
Abstract

Medical malpractice litigation against surgical residents is rarely discussed owing to assumed legal doctrine of respondeat superior, or "let the master answer."To better understand lawsuits targeting surgical trainees to prevent future litigation.Westlaw, an online legal research database containing legal records from across the United States, was retrospectively reviewed for malpractice cases involving surgical interns, residents, or fellows from January 1, 2005, to January 1, 2015. Infant-related obstetric and ophthalmologic procedures were excluded.Involvement in a medical malpractice case.Data were collected on patient demographics, case characteristics, and outcomes and were analyzed using descriptive statistics.During a 10-year period, 87 malpractice cases involving surgical trainees were identified. A total of 50 patients were female (57%), and 79 were 18 years of age or older (91%), with a median patient age of 44.5 years (interquartile range, 45-56 years). A total of 67 cases (77%) resulted in death or permanent disability. Most cases involved elective surgery (61 [70%]) and named a junior resident as a defendant (24 of 35 [69%]). Cases more often questioned the perioperative medical knowledge, decision making errors, and injuries (53 [61%]: preoperative, 19 of 53 [36%]) and postoperative, 34 of 53 [64%]) than intraoperative errors and injuries (43 [49%]). Junior residents were involved primarily with lawsuits related to medical decision making (21 of 24 [87%]). Residents' failure to evaluate the patient was cited in 10 cases (12%) and lack of direct supervision by attending physicians was cited in 48 cases (55%). A total of 42 cases (48%) resulted in a jury verdict or settlement in favor of the plaintiff, with a median payout of $900?000 (range, $1852 to $32 million).This review of malpractice cases involving surgical residents highlights the importance of perioperative management, particularly among junior residents, and the importance of appropriate supervision by attending physicians as targets for education on litigation prevention.

View details for DOI 10.1001/jamasurg.2017.2979

View details for PubMedID 28854303

View details for PubMedCentralID PMC5833625
Incorporation of Treatment Response, Tumor Grade and Receptor Status Improves Staging Quality in Breast Cancer Patients Treated with Neoadjuvant Chemotherapy. Annals of surgical oncology Bergquist, J. R., Murphy, B. L., Storlie, C. B., Habermann, E. B., Boughey, J. C. 2017; 24 (12): 3510?17
Abstract

Improved staging systems that better predict survival for breast cancer patients who receive neoadjuvant chemotherapy (NAC) by accounting for clinical pathological stage plus estrogen receptor (ER) and grade (CPS+EG) and ERBB2 status (Neo-Bioscore) have been proposed. We sought to evaluate the generalizability and performance of these staging systems in a national cohort.The National Cancer Database (2006-2012) was reviewed for patients with breast cancer who received NAC and survived ?90 days after surgery. Four systems were evaluated: clinical/pathologic American Joint Committee on Cancer (AJCC) 7th edition, CPS+EG, and Neo-Bioscore. Unadjusted Kaplan-Meier analysis and adjusted Cox proportional hazards models quantified overall survival (OS). Systems were compared using area under the curve (AUC) and integrated discrimination improvement (IDI).Overall, 43,320 patients (5-year OS 76.0, 95% confidence interval [CI] 75.4-76.5%) were included, 12,002 of whom had evaluable Neo-Bioscore. AUC at 5 years for CPS+EG (0.720, 95% CI 0.714-0.726) and Neo-Bioscore (0.729, 95% CI 0.716-0.742) were improved relative to AJCC clinical (0.650, 95% CI 0.643-0.656) and pathologic (0.683, 95% CI 0.676-0.689) staging. Both CPS+EG (IDI 7.2, 95% CI 6.6-7.7%) and Neo-Bioscore (IDI 9.8, 95% CI 8.0-11.6%) demonstrated superior discrimination when compared with AJCC clinical staging at 5 years. Comparison of CPS+EG with Neo-Bioscore yielded an IDI of 2.6% (95% CI 0.9-4.5%), indicating that Neo-Bioscore is the best staging system.In a heterogenous national cohort of breast cancer patients treated with NAC and surgery, the incorporation of chemotherapy response, tumor grade, ER status, and ERBB2 status into the staging system substantially improved on the AJCC TNM staging system in discrimination of OS. Neo-Bioscore provided the best staging discrimination.

View details for DOI 10.1245/s10434-017-6010-4

View details for PubMedID 28828583
Outcomes are Local: Patient, Disease, and Procedure-Specific Risk Factors for Colorectal Surgical Site Infections from a Single Institution. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Cima, R. R., Bergquist, J. R., Hanson, K. T., Thiels, C. A., Habermann, E. B. 2017; 21 (7): 1142?52
Abstract

Colorectal surgical site infections (SSIs) contribute to postoperative morbidity, mortality, and resource utilization. Risk factors associated with colorectal SSI are well-documented. However, quality improvement efforts are informed by national data, which may not identify institution-specific risk factors.Retrospective cohort study of colorectal surgery patients uses institutional ACS-NSQIP data from 2006 through 2014. ACS-NSQIP data were enhanced with additional variables from medical records. Multivariable logistic regression identified factors associated with SSI development.Of 2376 patients, 213 (9.0%) developed at least one SSI (superficial 4.8%, deep 1.1%, organ space 3.5%). Age�<�40, BMI�>�30, ASA3+, steroid use, smoking, diabetes, pre-operative sepsis, higher wound class, elevated WBC or serum glutamic-oxalocetic transaminase, low hematocrit or albumin, Crohn's disease, and prolonged incision-to-closure time were associated with increased SSI rate (all P�<�0.01). After adjustment, BMI�>�30, steroids, diabetes, and wound contamination were associated with SSI. Patients with Crohn's had greater odds of SSI than other indications.Institutional modeling of SSI suggests that many previously suggested risk factors established on a national level do not contribute to SSIs at our institution. Identification of institution-specific predictors of SSI, rather than relying upon conclusions derived from external data, is a critical endeavor in facilitating quality improvement and maximizing value of quality investments.

View details for DOI 10.1007/s11605-017-3430-1

View details for PubMedID 28470562
Preoperative Clostridium difficile Infection Does Not Affect Pouch Outcomes in Patients with Ulcerative Colitis Who Undergo Ileal Pouch-anal Anastomosis. Inflammatory bowel diseases Lightner, A. L., Tse, C. S., Quinn, K., Bergquist, J. R., Enders, F., Pendegraft, R., Khanna, S., Raffals, L. 2017; 23 (7): 1195?1201
Abstract

The operation of choice for patients with chronic ulcerative colitis (CUC) is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouchitis is the most common complication after IPAA. The incidence of Clostridium difficile infection (CDI) is higher in CUC patients than the general population and can lead to significant disease flares and higher rates of colectomy. We sought to determine the risk of pouchitis in patients with precolectomy CDI and 90-day postoperative IPAA complications.A retrospective case-control study was conducted on patients with CUC who underwent an IPAA between January 1, 2000 and January 10, 2015. The study cohort was comprised of patients diagnosed with CDI within 90 days before colectomy; patients with CUC without CDI comprised the control cohort. The primary outcome measure was the frequency of pouchitis after IPAA. Secondary outcomes included time to pouchitis, 90-day postoperative pouch morbidity: surgical site infection, hemorrhage, anastomotic leak, fistula formation, pouchitis treatment and response, and pouch failure requiring end-ileostomy or fecal diversion. Univariate and multivariable analysis was used to determine differences between CDI and non-CDI groups.Forty-eight case patients and 154 control patients were included. Patients with preoperative CDI were younger (P = 0.010), had higher rates of medically refractory disease (P = 0.002), and had greater use of biologic therapy (P = 0.046). The rate of pouchitis was 50.0% (n = 24) and 46.8% (n = 72) (P = 0.694) among patients with and without preoperative CDI, respectively. Patients with preoperative CDI who developed pouchitis post-IPAA were more likely to require medical management with an anti-TNF? (P = 0.042) and surgical management with end/diverting ileostomy (P = 0.042). Preoperative CDI was associated with higher rates of postoperative IPAA anastamotic or pouch strictures (P = 0.018). Multivariable analysis revealed primary sclerosing cholangitis (PSC) as the only variable associated with increased risk for pouchitis (OR 10.59; 95% CI, 3.07-51.08; P < 0.001).Preoperative CDI does not seem to be associated with an increased risk of pouchitis in patients with CUC.

View details for DOI 10.1097/MIB.0000000000001122

View details for PubMedID 28410344
Incorporation of CEA Improves Risk Stratification in Stage II Colon Cancer. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Spindler, B. A., Bergquist, J. R., Thiels, C. A., Habermann, E. B., Kelley, S. R., Larson, D. W., Mathis, K. L. 2017; 21 (5): 770?77
Abstract

High-risk features are used to direct adjuvant therapy for stage II colon cancer. Currently, high-risk features are identified postoperatively, limiting preoperative risk stratification. We hypothesized carcinoembryonic antigen (CEA) can improve preoperative risk stratification for stage II colon cancer. The National Cancer Database (NCDB 2004-2009) was reviewed for stage II colon adenocarcinoma patients undergoing curative intent resection. A novel risk stratification including both traditional high-risk features (T4 lesion, <12 lymph nodes sampled, and poor differentiation) and elevated CEA was developed. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards analyzed overall survival. Concordance Probability Estimates (CPE) assessed discrimination. Seventy-four thousand nine hundred forty-five patients were identified; 40,844 (54.5%) had CEA levels reported and were included. Chemotherapy administration was similar between normal and elevated CEA groups (23.8 vs. 25.1%, p?=?0.003). Compared to patients with CEA elevation, 5-year overall survival in patients with normal CEA was improved (74.5 vs. 63.4%, p?
View details for DOI 10.1007/s11605-017-3391-4

View details for PubMedID 28290141
Environmental exposures as a risk factor for fibrolamellar carcinoma. Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc Graham, R. P., Craig, J. R., Jin, L., Oliveira, A. M., Bergquist, J. R., Truty, M. J., Mounajjed, T., Greipp, P. T., Torbenson, M. S. 2017; 30 (6): 892?96
Abstract

Fibrolamellar carcinoma was first described in 1956. Subsequent large studies failed to identify cases before 1939 (the start of the World War II). This finding, combined with the presence of aryl hydrocarbon receptors on the tumor cells, have suggested that fibrolamellar carcinomas may be caused by environmental exposures that are new since World War II. To investigate this possibility, the surgical pathology files before 1939 were reviewed for hepatocellular carcinomas resected in young individuals. Two cases of fibrolamellar carcinoma were identified, from 1915 to 1924. The diagnosis of fibrolamellar carcinoma was confirmed at the histologic, ultrastructural and proteomic levels. These two fibrolamellar carcinoma cases clarify a key aspect of fibrolamellar carcinoma biology, reducing the likelihood that these tumors result exclusively from post World War II environmental exposures.

View details for DOI 10.1038/modpathol.2017.7

View details for PubMedID 28256571
Patient Selection for Neoadjuvant Therapy in Early-Stage Pancreatic Cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology Bergquist, J. R., Shubert, C. R., Storlie, C. B., Habermann, E. B., Truty, M. J. 2017; 35 (14): 1622?23
View details for DOI 10.1200/JCO.2016.71.2315

View details for PubMedID 28135141
Outcomes of Primary Colorectal Sarcoma: A National Cancer Data Base (NCDB) Review. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Thiels, C. A., Bergquist, J. R., Krajewski, A. C., Lee, H. E., Nelson, H., Mathis, K. L., Habermann, E. B., Cima, R. R. 2017; 21 (3): 560?68
Abstract

Primary colorectal sarcomas are a rare entity with anecdotally poor outcomes. We sought to inform surgeons, oncologists, and researchers of the characteristics and outcomes of these understudied and difficult-to-manage tumors.The National Cancer Data Base (NCDB) was queried for patients with pathologically confirmed primary sarcoma of the colon or rectum (1998-2012). Gastrointestinal stromal tumors were excluded. Unadjusted overall survival was reported using the Kaplan-Meier method. Patients with colorectal adenocarcinoma were used as a comparison cohort.Four hundred thirty-three patients with primary colorectal sarcoma were identified (57.5% leiomyosarcoma subtype). Median age was 63 [inter-quartile range 52, 75] years with 23.1% between the ages of 18 and 50 and 48.7% female. Majority of sarcomas were located in the colon (70.7%). When compared to 696,902 patients with adenocarcinoma, sarcoma patients were younger, had larger tumors, were more likely node negative and rectal in location, and higher grade (all p??0.05). Overall survival was lower at 5�years in patients with sarcoma (43.8%) than adenocarcinoma (52.3%, p?
View details for DOI 10.1007/s11605-016-3347-0

View details for PubMedID 28097468
Type of Resection (Whipple vs. Distal) Does Not Affect the National Failure to Provide Post-resection Adjuvant Chemotherapy in Localized Pancreatic Cancer. Annals of surgical oncology Bergquist, J. R., Ivanics, T., Shubert, C. R., Habermann, E. B., Smoot, R. L., Kendrick, M. L., Nagorney, D. M., Farnell, M. B., Truty, M. J. 2017; 24 (6): 1731?38
Abstract

Adjuvant chemotherapy improves survival after curative intent resection for localized pancreatic adenocarcinoma (PDAC). Given the differences in perioperative morbidity, we hypothesized that patients undergoing distal partial pancreatectomy (DPP) would receive adjuvant therapy more often those undergoing pancreatoduodenectomy (PD).The National Cancer Data Base (2004-2012) identified patients with localized PDAC undergoing DPP and PD, excluding neoadjuvant cases, and factors associated with receipt of adjuvant therapy were identified. Overall survival (OS) was analyzed using multivariable Cox proportional hazards regression.Overall, 13,501 patients were included (DPP, n�=�1933; PD, n�=�11,568). Prognostic characteristics were similar, except DPP patients had fewer N1 lesions, less often positive margins, more minimally invasive resections, and shorter hospital stay. The proportion of patients not receiving adjuvant chemotherapy was equivalent (DPP 33.7%, PD 32.0%; p�=�0.148). The type of procedure was not independently associated with adjuvant chemotherapy (hazard ratio 0.96, 95% confidence interval 0.90-1.02; p�=�0.150), and patients receiving adjuvant chemotherapy had improved unadjusted and adjusted OS compared with surgery alone. The type of resection did not predict adjusted mortality (p�=�0.870).Receipt of adjuvant chemotherapy did not vary by type of resection but improved survival independent of procedure performed. Factors other than type of resection appear to be driving the nationwide rates of post-resection adjuvant chemotherapy in localized PDAC.

View details for DOI 10.1245/s10434-016-5762-6

View details for PubMedID 28070725
Benefit of Postresection Adjuvant Chemotherapy for Stage III Colon Cancer in Octogenarians: Analysis of the National Cancer Database. Diseases of the colon and rectum Bergquist, J. R., Thiels, C. A., Spindler, B. A., Shubert, C. R., Hayman, A. V., Kelley, S. R., Larson, D. W., Habermann, E. B., Pemberton, J. H., Mathis, K. L. 2016; 59 (12): 1142?49
Abstract

Clinical trials demonstrate that postresection chemotherapy conveys survival benefit to patients with stage III colon cancer. It is unclear whether this benefit can be extrapolated to the elderly, who are underenrolled in clinical trials.The purpose of this study was to determine outcomes of selected octogenarians with stage III colon cancer with/without postresection adjuvant therapy.This was a retrospective cohort study (2006-2011) using unadjusted Kaplan-Meier and adjusted Cox proportional hazards analyses of overall survival.The study was conducted with the National Cancer Database.We included patients 80 to 89 years of age who were undergoing curative-intent surgery for stage III colon cancer and excluded patients who received neoadjuvant therapy, died within 6 weeks of surgery, or had high comorbidity.Overall survival was the main measure.A total of 8141 octogenarians were included; 3483 (42.8%) received postresection chemotherapy, and 4658 (57.2%) underwent surgery alone. Patients receiving chemotherapy were younger (82.0 vs 84.0 years; p < 0.001), healthier (73.1% vs 70.4% with no comorbidities; p = 0.009), and more likely to have N2 disease (40.4% vs 32.8%; p < 0.001). Overall survival was improved in patients receiving adjuvant chemotherapy (median = 61.7 vs 35.0 months; p < 0.001). Subgroup analysis of patients offered chemotherapy but refusing (n = 1315) demonstrated overall survival worse than those receiving adjuvant chemotherapy (median = 42.7 vs 61.7 months; p < 0.001). Multivariable analysis adjusting for potential confounders showed therapy with surgery alone to be independently associated with increased mortality hazard (HR = 1.83; p < 0.001), and the mortality hazard remained elevated in patients who voluntarily refused adjuvant therapy (HR = 1.45; p < 0.001).The study was limited by its retrospective, nonrandomized design.In selected octogenarians with stage III colon cancer, postresection adjuvant chemotherapy was associated with superior overall survival. However, less than half of the octogenarians with stage III colon cancer in the National Cancer Database received it. The remaining majority, who were all fit and survived ?6 weeks postsurgery, could have derived benefit from adjuvant chemotherapy. This represents a substantial opportunity for quality improvement in treating octogenarians with stage III colon cancer.

View details for DOI 10.1097/DCR.0000000000000699

View details for PubMedID 27824699
Small Cell Carcinoma of the Pancreas: A Surgical Disease. Pancreas Ivanics, T., Bergquist, J. R., Shubert, C. R., Smoot, R. L., Habermann, E. B., Truty, M. J. 2016; 45 (10): 1461?66
Abstract

Primary pancreatic small cell carcinomas (PSCCs) are rare, and benefits of surgery are unknown. Utilizing the National Cancer Data Base, surgical outcomes of PSCC were determined and compared with pancreatic ductal adenocarcinoma (PDAC).Patients with histologically confirmed PSCC (n = 541) and PDAC (n = 156,733) were identified from the National Cancer Data Base (1998-2011). Parametric comparisons of patient and outcomes data were made. Unadjusted Kaplan-Meier and Cox proportional hazards analyses were performed.Primary pancreatic small cell carcinomas accounted for 0.2% of all pancreatic tumors. Demographics were similar to PDAC. A higher proportion of PSCC were metastatic at diagnosis (75.6% vs 53.6%, P < 0.001). In stage I/II, 45.6% of PDAC versus 21.8% of PSCC underwent surgery. Node status, lymphovascular invasion, margin negativity rates, and perioperative outcomes were similar. Median unadjusted overall survival was similar for resected PDAC and PSCC (16.9 vs 20.7 months; P = 0.337). On multivariable analysis within resectable PSCC (stages I-II), the greatest independent predictors of mortality were age 65 years or older (hazards ratio, 2.78; 95% confidence interval, 1.56-4.97; P = 0.00055) and nonreceipt of surgery (hazards ratio, 2.66; 95% confidence interval, 1.24-5.71; P = 0.01).Although PSCC commonly presents with distant disease, patients with anatomically resectable tumors derive similar benefit from aggressive surgical intervention as PDAC and should be counseled accordingly.

View details for DOI 10.1097/MPA.0000000000000661

View details for PubMedID 27171519
Risk by indication for pancreaticoduodenectomy in patients 80 years and older: a study from the American College of Surgeons National Surgical Quality Improvement Program. HPB : the official journal of the International Hepato Pancreato Biliary Association Bergquist, J. R., Shubert, C. R., Ubl, D. S., Thiels, C. A., Kendrick, M. L., Truty, M. J., Habermann, E. B. 2016; 18 (11): 900?907
Abstract

Expected mortality after elective pancreaticoduodenectomy (PD) in contemporary series is less than 5% in elderly patients; however, to our knowledge, mortality rate has not been correlated with indication for PD. We hypothesized that perioperative risk following PD would correlate with diagnostic indication in older patients.The American College of Surgeons NSQIP database was reviewed to identify patients (<80�and�?80 years) who underwent PD from January 1, 2005, through December 31, 2012. High- and low-risk diagnoses were determined by using 30-day, major-morbidity data. Univariate and multivariable analyses were used to compare outcomes.Pancreatic cancer and chronic pancreatitis were found to be low-risk diagnoses in elderly patients, whereas bile duct and ampullary neoplasm, duodenal neoplasm, and neuroendocrine tumors were high-risk diagnoses. The risk of 30-day mortality for older patients (?80�y) undergoing PD was 6.1% for those with high-risk diagnoses vs 4.5% for those with low-risk diagnoses (P�=�.27). On multivariable analysis (controlling for confounders), a high-risk diagnosis was shown to be an independent predictor of prolonged length of stay, superficial surgical-site infection (SSI), and organ-space SSI. There was no increased risk of complications in patients ?80 years with low-risk diagnoses.In patients 80 or older undergoing PD, perioperative risk varies by diagnostic indication. Patients should receive preoperative counseling about their risk.

View details for DOI 10.1016/j.hpb.2016.07.012

View details for PubMedID 27594118

View details for PubMedCentralID PMC5094480
Mixed hepatocellular and cholangiocarcinoma: a rare tumor with a mix of parent phenotypic characteristics. HPB : the official journal of the International Hepato Pancreato Biliary Association Bergquist, J. R., Groeschl, R. T., Ivanics, T., Shubert, C. R., Habermann, E. B., Kendrick, M. L., Farnell, M. B., Nagorney, D. M., Truty, M. J., Smoot, R. L. 2016; 18 (11): 886?92
Abstract

Intrahepatic lesions of mixed hepatocellular (HCC) and intrahepatic cholangiocellular carcinoma (ICC) histology are rare. The aim was to describe the natural history of these tumors relative to monomorphic ICC or HCC utilizing the National Cancer Data Base (NCDB).Patients with ICC, HCC, and mixed histology (cHCC-CCA) were identified in the NCDB (2004-2012). Inter-group comparisons were made. Kaplan-Meier and multivariable Cox Proportional Hazards analyzed overall survival.The query identified 90,499 patients with HCC; 14,463 with ICC; and 1141 with cHCC-CCA histology. Patients with cHCC-CCA histology were relatively young (61 vs. 62 (HCC, p�=�0.877) and 67 (ICC, p�<�0.001) years) and more likely to have poorly differentiated tumor (29.2% vs. 10.3% (HCC) and 17.2% (ICC) p�<�0.001). Median overall survival for cHCC-CCA was 7.9 months vs. 10.8 (HCC) and 8.2 (ICC, all p�<�0.001). Stage-specific survival for mixed histology tumors was most similar to that of HCC for all stages. cHCC-CCA were transplanted at a relatively high rate, and transplant outcomes for mixed tumors were substantially worse than for HCC lesions.cHCC-CCA demonstrate stage-specific survival similar to HCC, but post-surgical survival more consistent with ICC. Patients with a pre-operative diagnosis of cHCC-CCA should undergo resection when appropriate.

View details for DOI 10.1016/j.hpb.2016.07.006

View details for PubMedID 27546172

View details for PubMedCentralID PMC5094489
Overall survival is increased among stage III pancreatic adenocarcinoma patients receiving neoadjuvant chemotherapy compared to surgery first and adjuvant chemotherapy: An intention to treat analysis of the National Cancer Database. Surgery Shubert, C. R., Bergquist, J. R., Groeschl, R. T., Habermann, E. B., Wilson, P. M., Truty, M. J., Smoot, R. L., Kendrick, M. L., Nagorney, D. M., Farnell, M. B. 2016; 160 (4): 1080?96
Abstract

Outcomes of neoadjuvant systemic therapy versus an upfront operation for clinical, stage�III pancreatic adenocarcinoma remain poorly defined. Our aim was to compare survival among patients receiving neoadjuvant chemotherapy versus surgery-first with an intention-to-treat analysis.The National Cancer Data Base was reviewed from 2002-2011 for patients with clinical, stage III adenocarcinoma of the head or body of the pancreas. Patients were categorized as neoadjuvant or surgery-first. The intention-to-treat analysis included all neoadjuvant therapy patients in whom a potentially curative operation was planned and all surgery-first patients for whom adjuvant therapy was recommended. Intention-to-treat overall survival was compared by Kaplan-Meier and Cox proportional hazards multivariable regression.A total of 593 patients were identified: 377 (63.6%) in the neoadjuvant cohort, wherein 104 (27.6%) experienced preoperative attrition, and 216 (36.4%) in the surgery-first cohort, of whom 30 (13.9%) failed to receive intended adjuvant chemotherapy. Intention-to-treat Kaplan-Meier analysis demonstrated superior survival for neoadjuvant compared to surgery-first (median overall survival 20.7�months vs 13.7�months, log rank P�<�.001). Intention-to-treat multivariable regression analysis revealed a decreased mortality hazard (hazard ratio�=�0.68, 95% confidence interval 0.53-0.86, P�=�.0012) for neoadjuvant compared to surgery-first.Despite preoperative attrition, neoadjuvant therapy in clinical, stage III pancreatic cancer patients is associated with improved overall survival when compared to patients receiving surgery-first.

View details for DOI 10.1016/j.surg.2016.06.010

View details for PubMedID 27522556
Implications of CA19-9 elevation for survival, staging, and treatment sequencing in intrahepatic cholangiocarcinoma: A national cohort analysis. Journal of surgical oncology Bergquist, J. R., Ivanics, T., Storlie, C. B., Groeschl, R. T., Tee, M. C., Habermann, E. B., Smoot, R. L., Kendrick, M. L., Farnell, M. B., Roberts, L. R., Gores, G. J., Nagorney, D. M., Truty, M. J. 2016; 114 (4): 475?82
Abstract

Optimal management of patients with intrahepatic cholangiocarcinoma (ICCA) and elevated CA19-9 remains undefined. We hypothesized CA19-9 elevation above normal indicates aggressive biology and that inclusion of CA19-9 would improve staging discrimination.The National Cancer Data Base (NCDB-2010-2012) was reviewed for patients with ICCA and reported CA19-9. Patients were stratified by CA19-9 above/below normal reference range. Unadjusted Kaplan-Meier and adjusted Cox-proportional-hazards analysis of overall survival (OS) were performed.A total of 2,816 patients were included: 938 (33.3%) normal; 1,878 (66.7%) elevated CA19-9 levels. Demographic/pathologic and chemotherapy/radiation were similar between groups, but patients with elevated CA19-9 had more nodal metastases and less likely to undergo resection. Among elevated-CA19-9 patients, stage-specific survival was decreased in all stages. Resected patients with CA19-9 elevation had similar peri-operative outcomes but decreased long-term survival. In adjusted analysis, CA19-9 elevation independently predicted increased mortality with impact similar to node-positivity, positive-margin resection, and non-receipt of chemotherapy. Proposed staging system including CA19-9 improved survival discrimination over AJCC 7th edition.Elevated CA19-9 is an independent risk factor for mortality in ICCA similar in impact to nodal metastases and positive resection margins. Inclusion of CA19-9 in a proposed staging system increases discrimination. Multi-disciplinary therapy should be considered in patients with ICCA and CA19-9 elevation. J. Surg. Oncol. 2016;114:475-482. � 2016 Wiley Periodicals, Inc.

View details for DOI 10.1002/jso.24381

View details for PubMedID 27439662

View details for PubMedCentralID PMC6038702
How matching may impact interpretation: Comments on "A matched-cohort analysis of 192 pancreatic anaplastic carcinomas and 960 pancreatic adenocarcinomas: A 13-year North American experience using the National Cancer Data Base (NCDB)". Surgery Bergquist, J. R., Thiels, C. A., Storlie, C. B., Nagorney, D. M., Truty, M. J. 2016; 160 (6): 1714?15
View details for DOI 10.1016/j.surg.2016.05.011

View details for PubMedID 27365227
Survival following synchronous colon cancer resection. Journal of surgical oncology Thiels, C. A., Naik, N. D., Bergquist, J. R., Spindler, B. A., Habermann, E. B., Kelley, S. R., Wolff, B. G., Mathis, K. L. 2016; 114 (1): 80?85
Abstract

Synchronous colon cancers, defined as two or more primary colon cancer detected simultaneously at the time of initial diagnosis, account for up to 5% of all colon cancer diagnoses. Management principles and outcomes remain largely undefined.A retrospective institutional review of patients undergoing curative intent resection for colon adenocarcinoma (Stages I-III) from 1995 to 2007 was performed. Hereditary causes or inflammatory bowel disease were excluded. Matching was performed and Kaplan-Meier analysis was used to compare overall survival.Of 2,387 patients, 100 (4.2%) had synchronous cancers. Patients with synchronous lesions tended to be older (median 77 vs. 72 years, P??0.05). Compared to solitary, synchronous cancers demonstrated an inferior 10-year overall survival (53.9% vs. 36.5%, P?=?0.009). Subset analysis of patients with synchronous cancers showed no difference in overall survival between those with extended versus segmental resections at 120-months (P?=?0.07).Synchronous colon cancer is associated with decreased overall survival compared to patients with solitary tumors. Extended resection does not confer a survival benefit in these patients. Further research is needed to determine how to mitigate the poor outcomes. J. Surg. Oncol. 2016;114:80-85. � 2016 Wiley Periodicals, Inc.

View details for DOI 10.1002/jso.24258

View details for PubMedID 27074754
Carbohydrate Antigen 19-9 Elevation in Anatomically Resectable, Early Stage Pancreatic Cancer Is Independently Associated with Decreased Overall Survival and an Indication for Neoadjuvant Therapy: A National Cancer Database Study. Journal of the American College of Surgeons Bergquist, J. R., Puig, C. A., Shubert, C. R., Groeschl, R. T., Habermann, E. B., Kendrick, M. L., Nagorney, D. M., Smoot, R. L., Farnell, M. B., Truty, M. J. 2016; 223 (1): 52?65
Abstract

Patient triage in anatomically resectable, early stage pancreatic ductal adenocarcinoma (PDAC) with elevated carbohydrate antigen 19-9 (CA 19-9) remains unclear. We hypothesized that any CA 19-9 elevation indicates biologically borderline resectability.The National Cancer Data Base (NCDB 2010 to 2012) was reviewed for PDAC patients with reported CA 19-9. Nonsecretors were analyzed separately. Early stage (I/II) patients were stratified by CA 19-9 above or below normal (37 U/mL). Unadjusted Kaplan-Meier and adjusted Cox proportional hazards survival modeling were performed.Of 113,145 patients, only 28,074 (24.8%) had CA 19-9 measured and reported, and this proportion was stage independent. Among early stage patients (n�= 10,806), there were 957 (8.8%) nonsecretors, 2,708 (25.1%) with normal levels, and 7,141 (66.1%) with elevated levels. Demographics and perioperative outcomes were similar between these groups. Survival was worse in all stages in patients with CA 19-9 elevation. Nonsecretors had survival similar to that of patients with normal levels. Early stage patients with elevated CA 19-9 had decreased survival at 1, 2, and 3 years (56% vs 68%, 30% vs 42%, 15% vs 25%, all p < 0.001) relative to patients with normal levels. Adjusted modeling confirmed this finding (hazard ratio [HR] 1.26, p < 0.001). Repeat modeling in the neoadjuvant cohort demonstrated this to be the only treatment sequence to completely abrogate increased mortality due to CA 19-9 elevation (p�= 0.11).The minority of PDAC patients have CA 19-9 measured and reported in NCDB. The CA 19-9 nonsecretors and normal-level patients achieve equivalent survival. Elevation of CA 19-9 is associated with decreased stage-specific survival, with the greatest difference in early stages. Neoadjuvant systemic therapy followed by curative intent surgery best mitigates the increased mortality hazard. Patients with PDAC who have elevated CA 19-9 levels at diagnosis are biologically borderline resectable regardless of anatomic resectability, and neoadjuvant systemic therapy is suggested.

View details for DOI 10.1016/j.jamcollsurg.2016.02.009

View details for PubMedID 27049786
Improving Communication Skills and Professionalism Among General Surgery Residents, One Page at a Time. Mayo Clinic proceedings Thiels, C. A., Bergquist, J. R., Pandian, T. K., Heller, S. F. 2016; 91 (4): 539?41
View details for DOI 10.1016/j.mayocp.2016.02.004

View details for PubMedID 27046531
Outcomes of Pancreaticoduodenectomy for Pancreatic Neuroendocrine Tumors: Are Combined Procedures Justified? Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Thiels, C. A., Bergquist, J. R., Laan, D. V., Croome, K. P., Smoot, R. L., Nagorney, D. M., Thompson, G. B., Kendrick, M. L., Farnell, M. B., Truty, M. J. 2016; 20 (5): 891?98
Abstract

Efficacy and outcomes of resection for pancreatic neuroendocrine tumors (pNET) are well established; specific data on outcomes for pancreaticoduodenectomy (PD), either alone or with combined procedures, are limited. A retrospective review of PDs for pNET (1998-2014) at our institution was conducted. Patients were categorized into standard PD (SPD) alone or combined PD (CPD) defined as patients undergoing concurrent vascular reconstruction or additional organ resection for curative intent. Kaplan-Meier survival analyses were performed. PD for pNET was performed for 95 patients. Tumors were functional in 11 patients (9�%). Twenty-six patients (28�%) underwent CPD. The 30/90-day mortality was 1.1/5.3�% respectively and similar between SPD and CPD (p?=?0.61/p?=?0.24). Five-year overall survival after PD for pNET was 85.1/71.9�% and similar between SPD/CPD groups (p?=?0.17). Recurrence-free and overall survival for low-grade tumors was 74.7/93.9�% at 5�years compared to only 14.8/49.7�% for high-grade tumors (p?
View details for DOI 10.1007/s11605-016-3102-6

View details for PubMedID 26925796
Failure of Colorectal Surgical Site Infection Predictive Models Applied to an Independent Dataset: Do They Add Value or Just Confusion? Journal of the American College of Surgeons Bergquist, J. R., Thiels, C. A., Etzioni, D. A., Habermann, E. B., Cima, R. R. 2016; 222 (4): 431?38
Abstract

Colorectal surgical site infections (C-SSIs) are a major source of postoperative morbidity. Institutional C-SSI rates are modeled and scrutinized, and there is increasing movement in the direction of public reporting. External validation of C-SSI risk prediction models is lacking. Factors governing C-SSI occurrence are complicated and multifactorial. We hypothesized that existing C-SSI prediction models have limited ability to accurately predict C-SSI in independent data.Colorectal resections identified from our institutional ACS-NSQIP dataset (2006 to 2014) were reviewed. The primary outcome was any C-SSI according to the ACS-NSQIP definition. Emergency cases were excluded. Published C-SSI risk scores: the National Nosocomial Infection Surveillance (NNIS), Contamination, Obesity, Laparotomy, and American Society of Anesthesiologists (ASA) class (COLA), Preventie Ziekenhuisinfecties door Surveillance (PREZIES), and NSQIP-based models were compared with receiver operating characteristic (ROC) analysis to evaluate discriminatory quality.There were 2,376 cases included, with an overall C-SSI rate of 9% (213 cases). None of the�models produced reliable and high quality C-SSI predictions. For any C-SSI, the NNIS c-index was 0.57 vs 0.61 for COLA, 0.58 for PREZIES, and 0.62 for NSQIP: all well below the minimum "reasonably" predictive c-index of 0.7. Predictions for superficial, deep, and organ space SSI were similarly poor.Published C-SSI risk prediction models do not accurately predict C-SSI in our independent institutional dataset. Application of externally developed prediction models to any individual practice must be validated or modified to account for institution and case-mix specific factors. This questions the validity of using externally or nationally developed models for "expected" outcomes and interhospital comparisons.

View details for DOI 10.1016/j.jamcollsurg.2015.12.034

View details for PubMedID 26847588
Outcomes with multimodal therapy for elderly patients with rectal cancer. The British journal of surgery Thiels, C. A., Bergquist, J. R., Meyers, A. J., Johnson, C. L., Behm, K. T., Hayman, A. V., Habermann, E. B., Larson, D. W., Mathis, K. L. 2016; 103 (2): e106?14
Abstract

Treatment guidelines for stage II and III rectal cancer include neoadjuvant chemoradiotherapy, surgery and postoperative adjuvant chemotherapy. Although data support this recommendation in younger patients, it is unclear whether this benefit can be extrapolated to elderly patients (aged 75 years or older).This was a retrospective review of patients aged at least 75 years with stage II or III rectal cancer who underwent surgery with curative intent from 1996 to 2013 at the Mayo Clinic. Kaplan-Meier analysis and log rank test were used to compare overall survival between therapy groups. Cox proportional hazards model was used to estimate the independent effect of treatment group on survival.A total of 160 elderly patients (median age 80 years) with stage II (66) and stage III (94) rectal cancer underwent surgical resection. Only 30�0 and 33�8 per cent received neoadjuvant or adjuvant therapy respectively. Among patients with stage II disease, there was no significant difference in 60-month survival between patients who received any additional therapy and those who had surgery alone (55 versus 38 per cent respectively; P = 0�184), whereas additional therapy improved survival in patients with stage III tumours (58 versus 30 per cent respectively; P = 0�007). Multivariable analysis found a survival benefit for additional therapy in elderly patients with stage III disease (hazard ratio 0�58, 95 per cent c.i. 0�34 to 0�98).A multimodal approach in elderly patients with stage III rectal cancer improved oncological outcomes.

View details for DOI 10.1002/bjs.10057

View details for PubMedID 26662377
Is Chemotherapy or Radiation Therapy in Addition to Surgery Beneficial for Locally Advanced Rectal Cancer in the Elderly? A National Cancer Data Base (NCDB) Study. World journal of surgery Bergquist, J. R., Thiels, C. A., Shubert, C. R., Habermann, E. B., Hayman, A. V., Zielinski, M. D., Mathis, K. L. 2016; 40 (2): 447?55
Abstract

Current National Comprehensive Cancer Network guidelines for Stages II and III rectal cancer recommend neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. It is unclear whether therapies in addition to surgery are truly beneficial in elderly patients. Our aim was to compare the survival of patients over 80 with Stages II and III rectal cancer undergoing curative intent surgery with or without additional therapy.The National Cancer Data Base (NCDB 2006-2011) was queried for patients over 80 with Stages II and III rectal cancer. The primary outcome was overall survival. Patients were stratified based upon therapy group. Univariate group comparisons were made. Unadjusted Kaplan-Meier and multivariable Cox proportional hazards modeling survival analyses were performed.The query yielded 3098 patients over 80 with Stage II (N = 1566) or Stage III (N = 1532) disease. Approximately, half of the patients received surgery only. Kaplan-Meier analysis showed improved survival for patients receiving neoadjuvant and/or adjuvant therapy in addition to surgery, but there was no significant difference between those that received guideline concordant care (GCC), neoadjuvant chemoradiation only, or post-operative chemotherapy only. Cox proportional hazard modeling identified age >90 and margin positivity as independent risk factors for decreased overall survival.Analysis of NCDB data for Stages II and III rectal cancer in patients over 80 shows a survival benefit of adjuvant and/or neoadjuvant therapy over surgery alone. There does not appear to be a difference in survival between patients who received neoadjuvant chemoradiation, post-resection adjuvant chemotherapy, or GCC.

View details for DOI 10.1007/s00268-015-3319-7

View details for PubMedID 26566779
A NSQIP Review of Major Morbidity and Mortality of Synchronous Liver Resection for Colorectal Metastasis Stratified by Extent of Liver Resection and Type of Colorectal Resection. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Shubert, C. R., Habermann, E. B., Bergquist, J. R., Thiels, C. A., Thomsen, K. M., Kremers, W. K., Kendrick, M. L., Cima, R. R., Nagorney, D. M. 2015; 19 (11): 1982?94
Abstract

Safety of synchronous hepatectomy and colorectal resection (CRR) for metastatic colorectal cancer remains controversial. We hypothesized that both the extent of hepatectomy and CRR influences postoperative outcomes.Prospective 2005-2013 ACS-NSQIP data were retrospectively reviewed for mortality and major morbidity (MM) after (1) isolated hepatectomy, (2) isolated CRR, and (3) synchronous resection for colorectal cancer. Hepatectomy and CRR risk categories were created based on mortality and MM of respective isolated resections. The synchronous cohort was then stratified based on risk categories. Cumulative asynchronous mortality and MM were estimated compared to that observed in the synchronous cohort via unadjusted relative risk and risk difference.There were 43,408 patients identified. Among isolated hepatectomy patients (N?=?6,661), trisectionectomy and right hepatectomy experienced the greatest mortality and were defined as "major" hepatectomy. Among isolated CRR patients (N?=?35,825), diverted left colectomy, abdominoperineal resection, total abdominal colectomy, and total abdominal proctocolectomy experienced the greatest MM and were defined as "high risk" CRR. Synchronous patients (N?=?922) were stratified by hepatectomy and CRR risk categories; mortality and MM varied from 0.9 to 5.0 % and 25.5 to 55.0 %, respectively. Mortality and MM were greatest for patients undergoing "high risk" CRR and "major" hepatectomy and lowest for synchronous CRR and "minor" hepatectomy. As both CRR and hepatectomy risk categories increased, there was a significant trend in increasing mortality and MM in synchronous patients. Additionally, comparison of the synchronous resections versus the estimated cumulative asynchronous outcomes showed that (1) mortality was significantly less after synchronous minor hepatectomy and either low or high risk CRR, and (2) neither mortality nor major morbidity differed significantly after major hepatectomy with either high or low risk CRR.Major morbidity after synchronous hepatic and colorectal resections vary incrementally and are related to both the risk of hepatectomy and CRR. Stratification of outcomes by the hepatectomy and CRR components may reflect a more accurate description of risks. Comparison of synchronous and combined outcomes of individual operations supports a potential benefit for synchronous resections with minor hepatectomy.

View details for DOI 10.1007/s11605-015-2895-z

View details for PubMedID 26239515
Does BMI affect the accuracy of preoperative axillary ultrasound in breast cancer patients? Annals of surgical oncology Shah, A. R., Glazebrook, K. N., Boughey, J. C., Hoskin, T. L., Shah, S. S., Bergquist, J. R., Dupont, S. C., Hieken, T. J. 2014; 21 (10): 3278?83
Abstract

Obesity affects 36 % of American women and is a well-documented breast cancer risk factor. Preoperative axillary ultrasound (AUS) is used routinely for axillary staging in newly diagnosed breast cancer patients; However, the impact of obesity on the usefulness of AUS is unknown. Our aim was to evaluate the effect of body mass index (BMI) on the performance of AUS.From our prospective breast surgery database, we identified 1,510 consecutive invasive breast cancers in patients undergoing primary surgery, including axillary operation, from January 2010 to July 2013. Preoperative AUS was performed in 1,375 cases (91 %). We analyzed patient, pathology and imaging data.Median BMI was 27.4 and 479 patients (36 %) were classified as obese (BMI ? 30). Most tumors were T1 (71 %) and estrogen receptor-positive (87 %). AUS was suspicious in 401 (29 %) patients, of whom 374 had ultrasound-guided lymph node fine-needle aspiration (FNA). Overall, 124 patients (33.2 %) were FNA positive. FNA identified disease preoperatively in 35.8 % of node-positive obese patients. For all BMI categories (normal, overweight, obese), AUS was predictive of pathologic nodal status (p < 0.0001). AUS sensitivity did not differ across BMI categories, while specificity and accuracy were better for overweight (p = 0.001 and 0.008, respectively) and obese (p = 0.007 and 0.02, respectively) patients, than for normal-BMI patients.Despite theoretical concern regarding both potential technical challenges and obesity-related lymph node alterations, the sensitivity of preoperative AUS for detecting nodal metastasis was similar in obese and non-obese patients, while specificity was better in obese patients. Preoperative AUS is valuable for preoperative nodal staging of obese breast cancer patients.

View details for DOI 10.1245/s10434-014-3902-4

View details for PubMedID 25074661

John Randol Bergquist

Clinical Scholar, Surgery - General SurgeryFellow in MedicineFellow in Medicine

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