Publications by authors named "Daniel O Herzig"

41 Publications

Assessment of a circular powered stapler for creation of anastomosis in left-sided colorectal surgery: A prospective cohort study.

Int J Surg 2020 Dec 8;84:140-146. Epub 2020 Nov 8.

Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 5 E 98th St 14th Fl, Ste D, New York, NY, 10029, USA.

Background: Circular staplers perform a critical function for creation of anastomoses in colorectal surgeries. Powered stapling systems allow for reduced force required by surgeons to fire the device and may provide advantages for creating a secure anastomosis. The objective of this study was to evaluate the clinical performance of a novel circular powered stapler in a post-market setting, during left-sided colectomy procedures.

Materials And Methods: Consecutive subjects underwent left-sided colorectal resections that included anastomosis performed with the ECHELON CIRCULAR™ Powered Stapler (ECP). The primary endpoint was the frequency in which a stapler performance issue was observed. Secondary endpoints included evaluation of ease of use of the device via a surgeon satisfaction questionnaire, and monitoring/recording of procedure-related adverse events (AEs).

Results: A total of 168 anastomoses were performed with the ECP. Surgical approaches included robotic-assisted (n = 74, 44.0%), laparoscopic (n = 71, 42.3%), open (n = 20, 11.9%), and hand-assisted minimally invasive (n = 3, 1.8%) procedures. There were 22 occurrences of device performance issues in 20 (11.9%) subjects during surgery. No positive intraoperative leak tests were observed, and only 1 issue was related to a procedure-related AE or surgical complication, which was an instance of incomplete surgical donut necessitating re-anastomosis. Postoperative anastomotic leaks were experienced in 4 (2.4%) subjects. Clavien-Dindo classification of all AEs indicated that 92.0% were Grades I or II. Participating surgeons rated the ECP as easier to use compared to previously used manual circular staplers in 85.7% of procedures.

Conclusion: The circular powered stapler exhibited few clinically relevant performance issues, an overall favorable safety profile, and ease of use for creation of left-sided colon anastomoses.
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http://dx.doi.org/10.1016/j.ijsu.2020.11.001DOI Listing
December 2020

The Authors Reply.

Dis Colon Rectum 2019 09;62(9):e414-e415

Department of Surgery, University of Arizona, Tucson, Arizona Divison of Colorectal Surgery, University of Minnesota, Minneapolis, Minnesota Division of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri Division of Colorectal Surgery, Columbia University, New York, New York Division of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio Divison of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1097/DCR.0000000000001431DOI Listing
September 2019

Who Undergoes Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Appendiceal Cancer? An Analysis of the National Cancer Database.

J Surg Res 2019 06 14;238:198-206. Epub 2019 Feb 14.

Oregon Health & Science University, Department of Surgery, Division of GI and General Surgery, Portland, Oregon. Electronic address:

Background: We sought to identify patterns of care for patients with appendiceal cancer and identify clinical factors associated with patient selection for multimodality treatment, including cytoreductive surgery and perioperative intraperitoneal chemotherapy (CRS/PIC).

Materials And Methods: National Cancer Database (NCDB) data from 2004 to 2014 of all diagnoses of appendiceal cancers were examined. We examined treatment modalities, as well as demographic, tumor-specific, and survival data. A multivariate logistic regression analysis was performed to determine the patient cohort most likely to receive CRS/PIC. Kaplan-Meier was used to estimate survival for all treatment groups. Significance was evaluated at P ≤ 0.05.

Results: We analyzed data on 18,055 patients. Nine thousand nine hundred ninety-two (55.3%) were treated with surgery only, 5848 (32.4%) received surgery and systemic chemotherapy, 1393 (7.71%) received CRS/PIC, 520 (2.88%) received chemotherapy alone, and 302 (1.67%) received neither surgery nor chemotherapy. Significant predictors of receiving CRS/PIC included male sex (OR 1.33, 95% CI: 1.11-1.59), white race (OR 2.00, 95% CI 1.40-2.86), non-Hispanic ethnicity (OR 1.92, 95% CI 1.21-3.05), private insurance (OR 1.52, 95% CI 1.26-1.84), and well-differentiated tumors (OR 4.25, CI: 3.39-5.32) (P < 0.05). Treatment with CRS/PIC was associated with a higher 5-year survival for mucinous malignancies, when compared to surgery alone (65.6% versus 62.4%, P < 0.01). Treatment with CRS/PIC was also associated with higher 5-year survival for well-differentiated malignancies, when compared to all other treatment modalities (74.9% versus 65.4%, P < 0.01).

Conclusions: Patients were more likely to undergo CRS/PIC if they were male, white, privately insured, and with well-differentiated tumors. CRS/PIC was associated with improved survival in patients with mucinous and low-grade tumors.
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http://dx.doi.org/10.1016/j.jss.2019.01.039DOI Listing
June 2019

Assessing the Value of Endoscopy Simulator Modules Designed to Prepare Residents for the Fundamentals of Endoscopic Surgery Examination.

Dis Colon Rectum 2019 02;62(2):211-216

Department of Surgery, Oregon Health & Science University, Portland, Oregon.

Background: The Fundamentals of Endoscopic Surgery examination is required for all general surgery residents. The test modules are not available for practice before the examination; however, similar modules are commercially available.

Objective: This study aims to determine which modules are most valuable for resident training and preparation for the examination by evaluating which correlates best with experience level.

Design: This was a single-institution study.

Setting: A virtual reality endoscopy simulator was utilized.

Participants: General surgery residents and faculty endoscopists performed endoscopy simulator modules (Endobasket 2, Endobubble 1 and 2, Mucosal Evaluation 2, and Basic Navigation) designed to prepare residents for the Fundamentals of Endoscopic Surgery examination. Residents were assigned into junior and senior groups based on the completion of a dedicated endoscopy rotation.

Main Outcome Measures: The primary outcomes measured were the mean time to completion, mean number of balloons popped, and mean number of wall hits for the 3 groups.

Results: A total of 21 junior residents, 11 senior residents, and 3 faculty participated. There were significant differences among groups in the mean time to completion for the Endobasket, Endobubble, and Mucosal Evaluation modules. The modules that correlated best with experience level were Endobubble 2 and Mucosal Evaluation 2. For Endobubble 2, juniors were slower than seniors, who were in turn slower than faculty (junior 118.8 ± 20.55 seconds, senior 100.3 ± 11.78 seconds, faculty 87.67 ± 2.848 seconds; p < 0.01). Juniors popped fewer balloons than seniors, who popped fewer balloons than faculty (junior 9.441 ± 3.838, senior 15.62 ± 4.133, faculty 28.78 ± 1.712; p < 0.001). For Mucosal Evaluation 2, juniors were slower than seniors, who were in turn slower than faculty (junior 468.8 ± 123.5 seconds, senior 368.6 ± 63.42 seconds, faculty 233.1 ± 70.45 seconds; p < 0.01).

Limitations: Study residents have not completed the Fundamentals of Endoscopic Surgery examinations, so correlation with examination performance is not yet possible.

Conclusions: Performance on Endobasket, Endobubble, and Mucosal Evaluation correlated well with experience level, providing benchmarks for each level to attain in preparation for the Fundamentals of Endoscopic Surgery examination. See Video Abstract at http://links.lww.com/DCR/A823.
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http://dx.doi.org/10.1097/DCR.0000000000001291DOI Listing
February 2019

Consolidation mFOLFOX6 Chemotherapy After Chemoradiotherapy Improves Survival in Patients With Locally Advanced Rectal Cancer: Final Results of a Multicenter Phase II Trial.

Dis Colon Rectum 2018 Oct;61(10):1146-1155

Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.

Background: Adding modified FOLFOX6 (folinic acid, fluorouracil, and oxaliplatin) after chemoradiotherapy and lengthening the chemoradiotherapy-to-surgery interval is associated with an increase in the proportion of rectal cancer patients with a pathological complete response.

Objective: The purpose of this study was to analyze disease-free and overall survival.

Design: This was a nonrandomized phase II trial.

Settings: The study was conducted at multiple institutions.

Patients: Four sequential study groups with stage II or III rectal cancer were included.

Intervention: All of the patients received 50 Gy of radiation with concurrent continuous infusion of fluorouracil for 5 weeks. Patients in each group received 0, 2, 4, or 6 cycles of modified FOLFOX6 after chemoradiation and before total mesorectal excision. Patients were recommended to receive adjuvant chemotherapy after surgery to complete a total of 8 cycles of modified FOLFOX6.

Main Outcome Measures: The trial was powered to detect differences in pathological complete response, which was reported previously. Disease-free and overall survival are the main outcomes for the current study.

Results: Of 259 patients, 211 had a complete follow-up. Median follow-up was 59 months (range, 9-125 mo). The mean number of total chemotherapy cycles differed among the 4 groups (p = 0.002), because one third of patients in the group assigned to no preoperative FOLFOX did not receive any adjuvant chemotherapy. Disease-free survival was significantly associated with study group, ypTNM stage, and pathological complete response (p = 0.004, <0.001, and 0.001). A secondary analysis including only patients who received ≥1 cycle of FOLFOX still showed differences in survival between study groups (p = 0.03).

Limitations: The trial was not randomized and was not powered to show differences in survival. Survival data were not available for 19% of the patients.

Conclusions: Adding modified FOLFOX6 after chemoradiotherapy and before total mesorectal excision increases compliance with systemic chemotherapy and disease-free survival in patients with locally advanced rectal cancer. Neoadjuvant consolidation chemotherapy may have benefits beyond increasing pathological complete response rates. See Video Abstract at http://links.lww.com/DCR/A739.
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http://dx.doi.org/10.1097/DCR.0000000000001207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6130918PMC
October 2018

Does a fine line exist between regional and metastatic pelvic lymph nodes in rectal cancer-striking discordance between national guidelines and treatment recommendations by US radiation oncologists.

J Gastrointest Oncol 2018 Jun;9(3):441-447

Department of Radiation Medicine, Oregon Health and Science University, Portland, OR, USA.

Background: Management of rectal cancer with involved lateral pelvic lymph nodes (LPLNs) at the time of diagnosis-the stage we refer institutionally to as Stage 3.5-is controversial. The American Joint Committee on Cancer's 7 edition classifies internal iliac lymph nodes (LNs) as regional (Stage III), but both external and common iliac LNs as metastatic (Stage IV). However, in many Asian countries all LPLNs are considered regional and patients are treated with curative intent, with literature supporting improved outcomes with LPLN dissection. Management patterns of these patients by US radiation oncologists (ROs) are unknown.

Methods: American ROs completed an anonymous institutional review board-approved online questionnaire regarding rectal cancer management.

Results: Among the 220 completed responses, 45% treat more than 10 patients annually and 39% work in academia. We found 10.5% and 34.2% recommend biopsy of clinically involved internal and common iliac LNs, respectively. The vast majority of responders-98.6% and 94.5%-treat involved internal and common iliac LNs with curative intent, respectively. Respondents recommend treatment intensification to involved internal iliac LNs by dissection of the nodal basin (88.2%) and radiation therapy (RT) boost (59.1%), and treatment intensification to involved common iliac LNs by LN dissection (76.4%) and RT boost (63.6%).

Conclusions: Our analysis reveals that the vast majority of US ROs approach patients with involved LPLNs, both regional (internal iliac) and metastatic (common iliac), with curative intent. They recommend treatment intensification with surgical resection and/or RT boost to involved nodes. Prospective clinical trials need to determine the appropriate management of patients with Stage 3.5 rectal cancer.
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http://dx.doi.org/10.21037/jgo.2018.02.05DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6006036PMC
June 2018

Preferential use of imaging modalities in staging newly diagnosed rectal cancer: a survey of US radiation oncologists.

J Gastrointest Oncol 2018 Jun;9(3):435-440

Department of Radiation Medicine, Oregon Health & Science University, Portland, OR, USA.

Background: Accurate staging is crucial for management of patients with newly diagnosed rectal cancer. Endorectal ultrasound (EUS) has been the standard modality in the United States for decades, with magnetic resonance imaging (MRI) now preferred by national guidelines. Positron emission tomography (PET), conversely, is not recommended. The current utilization of imaging modalities by American radiation oncologists in staging newly diagnosed rectal cancer is unknown.

Methods: American radiation oncologists completed an anonymous institutional review board-approved online survey probing their imaging preferences for initial staging of rectal cancer patients.

Results: We received 220 responses from American radiation oncologists, with 39% in academic centers and with 45% seeing more than 10 rectal cancer patients per year. Most respondents utilize all three imaging modalities for rectal cancer staging-EUS, MRI and positron emission tomography/computed tomography (PET/CT). Fifty-two percent and 38% of respondents are high utilizers of EUS and MRI, respectively, defined as ordering these tests at least 75% of the time. Forty seven percent were high PET utilizers. The latter was associated with practice in a private setting (P=0.015) and being within 10 years from residency training completion (P<0.01).

Conclusions: Our analysis reveals a dramatic discordance among national guidelines and the practice patterns among American radiation oncologists. More rely on PET for initial staging of rectal cancer patients than on pelvic MRI. Further research needs to determine the most effective imaging work-up of patients with an initial diagnosis of rectal cancer.
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http://dx.doi.org/10.21037/jgo.2018.01.19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6006040PMC
June 2018

Travel distance influences readmissions in colorectal cancer patients-what the primary operative team needs to know.

J Surg Res 2018 07 20;227:220-227. Epub 2018 Mar 20.

Department of General Surgery, Oregon Health and Sciences University, Portland, Oregon. Electronic address:

Background: Many colorectal cancer patients receive complex surgical care remotely. We hypothesized that their readmission rates would be adversely affected after accounting for differences in travel distance from primary/index hospital and correlate with mortality.

Materials And Methods: We identified 48,481 colorectal cancer patients in the Surveillance, Epidemiology and End Results (SEER)-Medicare database. Travel distance was calculated, using Google Maps, and SAS. Multivariate negative binomial regression was used to identify factors associated with readmission rates. Overall survival was analyzed, using Kaplan-Meier and Cox proportional hazard.

Results And Conclusions: Thirty-day readmissions occurred in 14.9% of the cohort, 27.5% of which were to a nonindex hospital. In the colon and rectal cancer cohorts, readmissions were 14.5% and 16.5%, respectively. Rectal cancer patients had an increase in readmission by 13% (incidence rate ratios [IRR] 1.13; 95% confidence interval [CI] 1.05-1.21). Factors associated with readmission were male gender, advanced disease, length of stay (LOS), discharge disposition, hospital volume, Charlson score, and poverty level (P < 0.05). Greater distance traveled increased the likelihood of readmission but did not affect mortality. Travel distance influences readmission rates but not mortality. Discharge readiness to decrease readmissions is essential for colorectal cancer patients discharged from index hospitals.
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http://dx.doi.org/10.1016/j.jss.2018.02.022DOI Listing
July 2018

The Authors Reply.

Dis Colon Rectum 2017 07;60(7):e596-e597

On behalf of the Clinical Practice Guideline Committee of the American Society of Colon and Rectal Surgeons.

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http://dx.doi.org/10.1097/DCR.0000000000000838DOI Listing
July 2017

Clinical Practice Guidelines for the Surgical Treatment of Patients With Lynch Syndrome.

Dis Colon Rectum 2017 Feb;60(2):137-143

Prepared on Behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons.

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http://dx.doi.org/10.1097/DCR.0000000000000785DOI Listing
February 2017

Variation in the Use of Chemoradiotherapy for Stage II and III Anal Cancer: Analysis of the National Cancer Data Base.

Ann Surg Oncol 2016 11 21;23(12):3934-3940. Epub 2016 Jul 21.

Department of Surgery, Oregon Health and Science University, Portland, OR, USA.

Background: Treatment for anal canal cancer has evolved from radical operations to definitive chemoradiotherapy (CRT), which allows for sphincter preservation in most patients.

Objective: The aim of this study was to examine the use of CRT for patients with stage II and III anal cancer, among different patient demographics, geographic regions, and facility types.

Methods: Utilizing the National Cancer Data Base, we examined patients with stage II and III anal canal squamous cell carcinoma from 2003 to 2010. Via univariate analysis, we examined patterns of treatment by patient demographics, tumor characteristics, geographic region, and facility type (academic vs. community). A multivariable logistic regression model was built to evaluate differences in treatment patterns when adjusting by age, sex, race, comorbidities, and stage.

Results: A total of 12,801 patients were analyzed, of which 11,312 (88 %) received CRT. After adjusting for confounders, CRT was less likely to be administered to males [odds ratio (OR) 0.61, 95 % confidence interval (CI) 0.54-0.69], Black patients (OR 0.70, 95 % CI 0.59-0.83), and those with multiple comorbidities (OR 0.60, 95 % CI 0.51-0.72). CRT was not as widely utilized in the West (OR 0.74, 95 % CI 0.59-0.93), and patients treated in academic-based centers were less likely to receive CRT (OR 0.81, 95 % CI 0.72-0.92). Improved median overall survival was observed when CRT was utilized (p = 0.008).

Conclusion: When controlling for age, sex, race, comorbidities, and stage, discrepancies in the use of CRT for anal cancer treatment exist between demographic subtypes, geographical regions, and facility types.
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http://dx.doi.org/10.1245/s10434-016-5431-9DOI Listing
November 2016

HIV positivity and anal cancer outcomes: A single-center experience.

Am J Surg 2016 May 23;211(5):886-93. Epub 2016 Feb 23.

Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode L223A, Portland, OR 97239, USA. Electronic address:

Background: Anal cancer remains common among human immunodeficiency virus (HIV) patients. Chemoradiation has had mixed results. We evaluated outcome differences by HIV status.

Methods: We retrospectively analyzed 14 HIV+ and 72 HIV- anal cancer patients (2000 to 2013). Outcomes included chemoradiation tolerance, recurrence, and survival.

Results: HIV+ patients were more often male (100% vs 38%, P < .001) but diagnosed at similar stages (P = .49). They were less likely to receive traditional chemotherapy (36% vs 86%, P < .001). Recurrence (P = .55) and survival time (P = .48) were similar across groups. HIV+ patients had similar colostomy-free survival (P = .053). Receipt of 5-fluorouracil/mitomycin C (MMC) chemotherapy predicted recurrence-free and overall survival (Hazard ratios .278, .32). HIV status did not worsen recurrence (P = .71) or survival (P = .57).

Conclusions: HIV+ patients received more non-MMC-based chemoradiation but had equivalent colostomy-free, recurrence, and overall survival. Use of 5-fluorouracil/MMC chemotherapy increased after 2008.
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http://dx.doi.org/10.1016/j.amjsurg.2016.01.009DOI Listing
May 2016

Nomogram for Predicting Overall Survival and Salvage Abdominoperineal Resection for Patients with Anal Cancer.

Dis Colon Rectum 2016 Jan;59(1):1-7

1 Department of Surgery, Oregon Health & Science University, Portland, Oregon 2 Fariborz Maseeh Department of Math & Statistics, Portland State University, Portland, Oregon 3 Department of Surgical Oncology, Oregon Health & Science University, Portland, Oregon 4 Department of Radiation Oncology, Oregon Health & Science University, Portland, Oregon.

Background: Anal cancer treatment has evolved from abdominoperineal resection to chemoradiotherapy, which allows for sphincter preservation.

Objective: The aim of this study was to develop an accurate model and nomogram to predict overall survival and the probability of salvage abdominoperineal resection for anal cancer patients.

Design: This is a retrospective cohort study.

Settings: Data were gathered from National Cancer Database entries from 1998 to 2010.

Patients: Patients with de novo anal cancer were selected from the National Cancer Database in the years 1998 through 2010; 1778 patients were included, and their data were analyzed.

Main Outcome Measures: Variables included time to death, censoring indicator, age, race, sex, tumor size, year of diagnosis, surgery status, nodal status, TNM stage, and chemoradiation therapy. A stratified Cox proportional hazards model for overall survival and a logistic regression model for salvage abdominoperineal resection were developed. Our final models were internally validated for discrimination and validation.

Results: Statistically significant variables in the salvage surgery model were tumor size and nodal status (p ≤ 0.001). For overall survival model, statistically significant variables (all with p ≤ 0.005), fitted across the strata of TNM clinical stage included age, sex, tumor size, nodal status, chemoradiotherapy treatment, and combination salvage surgery and chemoradiotherapy. Nomograms that predict events are based on our final models.

Limitations: Limitations included clerical database errors and nonmeasured variables, such as HIV status.

Conclusions: A nomogram can predict overall survival and salvage surgery for an individual with anal cancer. Such tools may be used as decision support aids to guide therapy and predict whether or not patients may need salvage surgery.
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http://dx.doi.org/10.1097/DCR.0000000000000507DOI Listing
January 2016

Psychiatric Illness is a Disparity in the Surgical Management of Rectal Cancer.

Ann Surg Oncol 2015 Dec 11;22 Suppl 3:S573-9. Epub 2015 Sep 11.

Department of Surgery, Oregon Health and Science University, Portland, OR, USA.

Background: Psychiatric disorders are common in the US and represent a major health disparity but little is known about their impact on surgical management and outcomes in cancer.

Objective: The aim of this study was to determine whether rectal cancer patients with psychiatric diagnoses have fewer sphincter-preserving procedures and higher postoperative complications.

Methods: Overall, 23,914 patients from the Nationwide Inpatient Sample (NIS) who underwent surgery for rectal cancer from 2004 to 2011 were identified. Patients with comorbid common psychiatric diagnoses were identified by International Classification of Diseases, Ninth Revision (ICD-9) codes. Main outcomes were measured by operation performed, length of stay (LOS), postoperative complications, and discharge disposition.

Results: Twenty percent of patients had a psychiatric diagnosis, with substance use being the most common psychiatric disorder (63 %). Patients with psychiatric diagnoses were more likely to be younger, White, have lower income, and have Medicaid insurance (p < 0.001) than those without. In a logistic regression model, patients with any psychiatric diagnosis were less likely to have sphincter-sparing surgery, controlling for patient sociodemographics, Charlson score, hospital procedure volume, and year (odds ratio 0.77; 95 % CI 0.72-0.83). LOS and postoperative complications were similar among the cohorts. Patients with psychiatric disorders were more likely to have home health care at discharge (p < 0.001).

Conclusions: Fewer sphincter-sparing procedures were performed on rectal cancer patients with psychiatric diagnoses. However, no significant differences in postoperative complications were observed.
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http://dx.doi.org/10.1245/s10434-015-4791-xDOI Listing
December 2015

Trends in the Surgical Management of Crohn's Disease.

J Gastrointest Surg 2015 Oct 19;19(10):1862-8. Epub 2015 Aug 19.

Department of Surgery, Division of Colorectal Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd., Mail Code L223A, 97239, Portland, OR, USA.

Introduction: Although medical management of Crohn's disease has changed in recent years, it is unclear whether surgical management has altered. We examined rate changes of surgical interventions, stoma constructions, and subset of ileostomy and colostomy constructions.

Materials And Methods: We reviewed the Nationwide Inpatient Sample database from 1988 to 2011. We examined the number of Crohn's-related operations and stoma constructions, including ileostomies and colostomies; a multivariable logistic regression model was developed.

Results: A total of 355,239 Crohn's-related operations were analyzed. Operations increased from 13,955 in 1988 to 17,577 in 2011, p < 0.001. Stoma construction increased from 2493 to 4283, p < 0.001. The subset of ileostomies increased from 1201 to 3169, p < 0.001 while colostomies decreased from 1351 to 1201, p = 0.05. Operation percentages resulting in stoma construction increased from 18 to 24 %, p < 0.001. Weight loss (OR 2.25, 95 % CI 1.88, 2.69) and presence of perianal fistulizing disease (OR 2.91, 95 % CI 2.31, 3.67) were most predictive for requiring stoma construction.

Conclusions: Crohn's-related surgical interventions and stoma constructions have increased. The largest predictors for stoma construction are weight loss and perianal fistulizing disease. As a result, nutrition should be optimized and the early involvement of a multidisciplinary team should be considered.
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http://dx.doi.org/10.1007/s11605-015-2911-3DOI Listing
October 2015

Effect of adding mFOLFOX6 after neoadjuvant chemoradiation in locally advanced rectal cancer: a multicentre, phase 2 trial.

Lancet Oncol 2015 Aug 14;16(8):957-66. Epub 2015 Jul 14.

Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Background: Patients with locally advanced rectal cancer who achieve a pathological complete response to neoadjuvant chemoradiation have an improved prognosis. The need for surgery in these patients has been questioned, but the proportion of patients achieving a pathological complete response is small. We aimed to assess whether adding cycles of mFOLFOX6 between chemoradiation and surgery increased the proportion of patients achieving a pathological complete response.

Methods: We did a phase 2, non-randomised trial consisting of four sequential study groups of patients with stage II-III locally advanced rectal cancer at 17 institutions in the USA and Canada. All patients received chemoradiation (fluorouracil 225 mg/m(2) per day by continuous infusion throughout radiotherapy, and 45·0 Gy in 25 fractions, 5 days per week for 5 weeks, followed by a minimum boost of 5·4 Gy). Patients in group 1 had total mesorectal excision 6-8 weeks after chemoradiation. Patients in groups 2-4 received two, four, or six cycles of mFOLFOX6, respectively, between chemoradiation and total mesorectal excision. Each cycle of mFOLFOX6 consisted of racemic leucovorin 200 mg/m(2) or 400 mg/m(2), according to the discretion of the treating investigator, oxaliplatin 85 mg/m(2) in a 2-h infusion, bolus fluorouracil 400 mg/m(2) on day 1, and a 46-h infusion of fluorouracil 2400 mg/m(2). The primary endpoint was the proportion of patients who achieved a pathological complete response, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00335816.

Findings: Between March 24, 2004, and Nov 16, 2012, 292 patients were registered, 259 of whom (60 in group 1, 67 in group 2, 67 in group 3, and 65 in group 4) met criteria for analysis. 11 (18%, 95% CI 10-30) of 60 patients in group 1, 17 (25%, 16-37) of 67 in group 2, 20 (30%, 19-42) of 67 in group 3, and 25 (38%, 27-51) of 65 in group 4 achieved a pathological complete response (p=0·0036). Study group was independently associated with pathological complete response (group 4 compared with group 1 odds ratio 3·49, 95% CI 1·39-8·75; p=0·011). In group 2, two (3%) of 67 patients had grade 3 adverse events associated with the neoadjuvant administration of mFOLFOX6 and one (1%) had a grade 4 adverse event; in group 3, 12 (18%) of 67 patients had grade 3 adverse events; in group 4, 18 (28%) of 65 patients had grade 3 adverse events and five (8%) had grade 4 adverse events. The most common grade 3 or higher adverse events associated with the neoadjuvant administration of mFOLFOX6 across groups 2-4 were neutropenia (five in group 3 and six in group 4) and lymphopenia (three in group 3 and four in group 4). Across all study groups, 25 grade 3 or worse surgery-related complications occurred (ten in group 1, five in group 2, three in group 3, and seven in group 4); the most common were pelvic abscesses (seven patients) and anastomotic leaks (seven patients).

Interpretation: Delivery of mFOLFOX6 after chemoradiation and before total mesorectal excision has the potential to increase the proportion of patients eligible for less invasive treatment strategies; this strategy is being tested in phase 3 clinical trials.

Funding: National Institutes of Health National Cancer Institute.
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http://dx.doi.org/10.1016/S1470-2045(15)00004-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4670237PMC
August 2015

Strictureplasty for Treatment of Crohn's Disease: an ACS-NSQIP Database Analysis.

J Gastrointest Surg 2015 May 24;19(5):905-10. Epub 2015 Jan 24.

Department of Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Mail Code L223A, Portland, OR, 97239, USA,

Introduction: Strictureplasty is an alternative to resection for treatment of Crohn's disease (CD) strictures. It preserves bowel length, and specialized centers report favorable outcomes. Strictureplasty rates, however, are thought to be low, and it was recently removed from required cases for colon and rectal surgery residents. We examined operative characteristics, and trends in its use using a large national database.

Materials And Methods: We examined the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012, identifying patients with CD who underwent strictureplasty. We identified patient characteristics, outcome variables, and trends in utilization of strictureplasty.

Results: A total of 9172 patients underwent surgery for CD. Two hundred fifty-six (2.8 %) underwent strictureplasty. Median preoperative albumin was 3.6. Preoperative steroid use and weight loss rates were 39 and 8 %. Rates of wound infection and organ space infection were 11 and 4 %. Rate of reoperation was 6 %. Outcomes did not change significantly over time (all p = NS). The proportion of CD operations that included a strictureplasty decreased from 5.1 to 1.7 % (OR 0.902 with each additional year, 95 % CI (0.852, 0.960), p < 0.001).

Conclusion: Strictureplasty as treatment for CD is decreasing in the ACS-NSQIP database. Infectious complications and reoperation rates following strictureplasty are low and have not changed over time.
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http://dx.doi.org/10.1007/s11605-015-2749-8DOI Listing
May 2015

Initial surgical management of ulcerative colitis in the biologic era.

Dis Colon Rectum 2014 Dec;57(12):1358-63

1Department of Surgery, Oregon Health & Science University, Portland, Oregon 2Department of Gastroenterology, Oregon Health & Science University, Portland, Oregon.

Background: The initial minimum operation for ulcerative colitis is a total abdominal colectomy. Healthy patients may undergo proctectomy at the same time; however, for ill patients, proctectomy is delayed. Since the introduction of biologic medications in 2005, ulcerative colitis medical management has changed dramatically.

Objective: We examined how operative management for ulcerative colitis has changed from the prebiologic to biologic eras.

Design: We conducted a retrospective review of data on patients with ulcerative colitis who were included in the Nationwide Inpatient Sample database.

Settings: This study was conducted at a single university.

Patients: A total of 1,547,852 patients with ulcerative colitis who were admitted to a US hospital from 1991 to 2011 were included in the study.

Main Outcome Measures: We examined patients whose initial operation consisted of total abdominal colectomy without proctectomy versus a total proctocolectomy with or without a pouch. We also examined which operation was done at the time of the construction of an ileoanal pouch. Patients who underwent colectomy and pouch construction in the same hospitalization were compared with those who received pouch formation at a subsequent hospitalization.

Results: Ulcerative colitis-related admissions rose by 170% during the years examined, and the number of patients who required total abdominal colectomy increased by 44%. Total abdominal colectomy increased by 15%, as opposed to total proctocolectomy (p < 0.001). Pouch construction at a subsequent operation increased by 16% (p = 0.002). Since 2008, total abdominal colectomy has surpassed total proctocolectomy as the most common initial surgical intervention for ulcerative colitis.

Limitations: The Nationwide Inpatient Sample is a retrospective database, and we were limited to examining the variables within it.

Conclusions: Total abdominal colectomy is currently the most common initial operation for patients with ulcerative colitis, and an ileoanal pouch is more frequently constructed at a subsequent hospitalization. These trends coincide with the initiation of biologic treatments and may imply that patients are acutely ill at the time of initial operation. Alternately, there may be surgeon-perceived bias of increased surgical risk or a shift in care to specialized surgeons for pouch construction.
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http://dx.doi.org/10.1097/DCR.0000000000000236DOI Listing
December 2014

Molecular markers for colon diagnosis, prognosis and targeted therapy.

J Surg Oncol 2015 Jan 8;111(1):96-102. Epub 2014 Oct 8.

Department of Surgery, Oregon Health & Science University, Portland, Oregon.

Colorectal adenocarcinoma (CRC), the second leading cancer-related death in the United States, remains a global public health issue. Sporadic CRC is considered the result of sequential mucosal changes from normal colonic mucosa to adenocarcinoma. Efforts in understanding the molecular pathways leading to CRC tumorigenesis may lead to identifying novel, individually tailored therapeutic targets for patients. In this review, we focus on well-published prognostic and predictive markers in CRC and examine their role in clinical practice.
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http://dx.doi.org/10.1002/jso.23806DOI Listing
January 2015

Addressing the appropriateness of elective colon resection for diverticulitis: a report from the SCOAP CERTAIN collaborative.

Ann Surg 2014 Sep;260(3):533-8; discussion 538-9

*Department of Surgery, University of Washington, Seattle †Department of Surgery, Swedish Medical Center, Seattle, WA ‡Surgical Care and Outcomes Assessment Program (SCOAP), Seattle, WA §Department of Surgery, Oregon Health & Science University, Portland ¶Department of Surgery, Madigan Army Medical Center, Tacoma, WA ‖Department of Surgery, Virginia Mason Medical Center, Seattle, WA.

Objective: To assess the reported indications for elective colon resection for diverticulitis and concordance with professional guidelines.

Background: Despite modern professional guidelines recommending delay in elective colon resection beyond 2 episodes of uncomplicated diverticulitis, the incidence of elective colectomy has increased dramatically in the last 2 decades. Whether surgeons have changed their threshold for recommending a surgical intervention is unknown. In 2010, Washington State's Surgical Care and Outcomes Assessment Program initiated a benchmarking and education initiative related to the indications for colon resection.

Methods: Prospective cohort study evaluating indications from chronic complications (fistula, stricture, bleeding) or the number of previously treated diverticulitis episodes for patients undergoing elective colectomy at 1 of 49 participating hospitals (2010-2013).

Results: Among 2724 patients (58.7 ± 13 years; 46% men), 29.4% had a chronic complication indication (15.6% fistula, 7.4% stricture, 3.0% bleeding, 5.8% other). For the 70.5% with an episode-based indication, 39.4% had 2 or fewer episodes, 56.5% had 3 to 10 episodes, and 4.1% had more than 10 episodes. Thirty-one percent of patients failed to meet indications for either a chronic complication or 3 or more episodes. Over the 4 years, the proportion of patients with an indication of 3 or more episodes increased from 36.6% to 52.7% (P < 0.001) whereas the proportion of those who failed to meet either clinical or episode-based indications decreased from 38.4% to 26.4% (P < 0.001). The annual rate of emergency resections did not increase significantly, varying from 5.6 to 5.9 per year (P = 0.81).

Conclusions: Adherence to a guideline based on 3 or more episodes for elective colectomy increased concurrently with a benchmarking and peer-to-peer messaging initiative. Improving adherence to professional guidelines related to appropriate care is critical and can be facilitated by quality improvement collaboratives.
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http://dx.doi.org/10.1097/SLA.0000000000000894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4160115PMC
September 2014

Chemoradiotherapy with a radiation boost for anal cancer decreases the risk for salvage abdominoperineal resection: analysis from the national cancer data base.

Ann Surg Oncol 2014 Oct 20;21(11):3616-20. Epub 2014 Jun 20.

Department of Surgery, Division of General & Gastrointestinal Surgery, Oregon Health & Science University, Portland, OR, USA,

Background: Chemoradiotherapy (CRT), the primary treatment for anal cancer, achieves complete tumor regression in most patients. Abdominoperineal resection (APR) is reserved for persistent or recurrent disease. An additional boost dose of radiation after CRT often is used to improve the response rate for advanced local disease (T3, 4, and N+). This study examines the need for salvage APR after radiation boost.

Methods: Patients with de novo anal cancer in the National Cancer Data Base from the years 2004-2010 were analyzed. Patients with missing data points or who did not receive standard CRT were excluded. Variables included age, gender, race, primary tumor size, clinical nodal status, TNM stage, radiation boost, and APR. A logistic regression model assessing the relationship between boost radiation and APR was developed.

Results: Of 1,025 patients meeting inclusion criteria, 450 patients received CRT without a radiation boost and 575 patients received CRT with a radiation boost. The two groups were similar in age, gender, race, tumor size, nodal status, and TNM stage (p values all >0.05). Significant multivariate predictors of salvage APR were tumor size, negative nodal status, and boost RT (all p < 0.05), whereas gender, age, race, and TNM stage were not significant (all p > 0.05). When controlling for age, tumor size, and nodal status, salvage APR is less likely to occur after boost RT (odds ratio 0.63; 95 % confidence interval 0.47, 0.85; p = 0.003).

Conclusions: When controlling for age, tumor size, and nodal status, those who received boost radiation for anal cancer were less likely to require salvage APR.
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http://dx.doi.org/10.1245/s10434-014-3849-5DOI Listing
October 2014

Increasing the number of lymph nodes examined after colectomy does not improve colon cancer staging.

J Am Coll Surg 2014 May 24;218(5):1004-11. Epub 2014 Jan 24.

Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR.

Background: Current quality initiatives call for examination of at least 12 lymph nodes in curative colon cancer resections. The aim of this study was to determine if the number of nodes harvested has increased, and if the increased number nodes correlates with improved staging or overall survival.

Study Design: A review of the Surveillance, Epidemiology, and End Results program database from 2004-2010 was performed. All patients who underwent colon cancer resection during this date range were analyzed. Number of nodes retrieved, patient stage, overall survival, and overall survival by stage were examined. Multivariable analysis controlled for stage, cancer site, age, year of diagnosis, and number of nodes retrieved. Improved staging was defined as increased detection of stage III patients.

Results: A total of 147,076 patients met inclusion criteria. Median number of nodes analyzed increased sequentially with each year examined, from 12 in 2004 to 17 in 2010. Despite greater number of total nodes obtained and analyzed, there was no increase in the percentage of patients with positive nodes (stage III disease). On multivariable analysis, after controlling for stage, site of disease, age, and year of diagnosis, there was a slight overall survival benefit with increasing nodal retrieval (hazard ratio = 0.987 for each additional node removed; 95% CI, 0.986-0.988; p < 0.001).

Conclusions: Since quality initiatives have been put in place, there has been an increase in the number of nodes examined in colon cancer resections, but no improvement in staging. The improved survival seen with higher node counts was independent of stage, site of disease, patient age, and year of diagnosis.
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http://dx.doi.org/10.1016/j.jamcollsurg.2014.01.039DOI Listing
May 2014

A virtual reality endoscopic simulator augments general surgery resident cancer education as measured by performance improvement.

J Cancer Educ 2014 Jun;29(2):333-6

Department of Surgery, Division of General and Gastrointestinal Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Mail code L223-A, Portland, OR, 97239, USA.

Colorectal cancer is the second most common cause of death in the USA. The need for screening colonoscopies, and thus adequately trained endoscopists, particularly in rural areas, is on the rise. Recent increases in required endoscopic cases for surgical resident graduation by the Surgery Residency Review Committee (RRC) further emphasize the need for more effective endoscopic training during residency to determine if a virtual reality colonoscopy simulator enhances surgical resident endoscopic education by detecting improvement in colonoscopy skills before and after 6 weeks of formal clinical endoscopic training. We conducted a retrospective review of prospectively collected surgery resident data on an endoscopy simulator. Residents performed four different clinical scenarios on the endoscopic simulator before and after a 6-week endoscopic training course. Data were collected over a 5-year period from 94 different residents performing a total of 795 colonoscopic simulation scenarios. Main outcome measures included time to cecal intubation, "red out" time, and severity of simulated patient discomfort (mild, moderate, severe, extreme) during colonoscopy scenarios. Average time to intubation of the cecum was 6.8 min for those residents who had not undergone endoscopic training versus 4.4 min for those who had undergone endoscopic training (p < 0.001). Residents who could be compared against themselves (pre vs. post-training), cecal intubation times decreased from 7.1 to 4.3 min (p < 0.001). Post-endoscopy rotation residents caused less severe discomfort during simulated colonoscopy than pre-endoscopy rotation residents (4 vs. 10%; p = 0.004). Virtual reality endoscopic simulation is an effective tool for both augmenting surgical resident endoscopy cancer education and measuring improvement in resident performance after formal clinical endoscopic training.
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http://dx.doi.org/10.1007/s13187-014-0610-5DOI Listing
June 2014

Care of the patient with anorectal trauma.

Authors:
Daniel O Herzig

Clin Colon Rectal Surg 2012 Dec;25(4):210-3

Department of Surgery, Digestive Health Center & Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon.

Blunt and penetrating injuries to the anus and rectum are uncommon. Considerable debate remains regarding the optimal treatment of rectal injuries. Although intraperitoneal rectal injuries can be treated similarly to colonic injuries, treatment options for extraperitoneal injuries include fecal diversion with a colostomy, presacral drainage, repair of the rectal defect, and distal rectal washout. Perineal injuries resulting in anal sphincter disruption often occur with severe associated injuries. Small defects can be repaired primarily, but extensive injuries often require diversion and sphincter reconstruction.
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http://dx.doi.org/10.1055/s-0032-1329391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3577610PMC
December 2012

Stage III & IV colon and rectal cancers share a similar genetic profile: a review of the Oregon Colorectal Cancer Registry.

Am J Surg 2013 May;205(5):608-12; discussion 612

Intermountain Healthcare, Murray, UT, USA.

Background: Determining the molecular profile of colon and rectal cancers offers the possibility of personalized cancer treatment. The purpose of this study was to determine whether known genetic mutations associated with colorectal carcinogenesis differ between colon and rectal cancers and whether they are associated with survival.

Methods: The Oregon Colorectal Cancer Registry is a prospectively maintained, institutional review board-approved tissue repository with associated demographic and clinical information. The registry was queried for any patient with molecular analysis paired with clinical data. Patient demographics, tumor characteristics, microsatellite instability status, and mutational analysis for p53, AKT, BRAF, KRAS, MET, NRAS, and PIK3CA were analyzed. Categorical variables were compared using chi-square tests. Continuous variables between groups were analyzed using Mann-Whitney U tests. Kaplan-Meier analysis was used for survival studies. Comparisons of survival were made using log-rank tests.

Results: The registry included 370 patients: 69% with colon cancer and 31% with rectal cancer. Eighty percent of colon cancers and 68% of rectal cancers were stages III and IV. Mutational analysis found no significant differences in detected mutations between colon and rectal cancers, except that there were significantly more BRAF mutations in colon cancers compared with rectal cancers (10% vs 0%, P < .008). No differences were seen in 5-year survival rates of patients with colon versus rectal cancers when stratified by the presence of KRAS, PIK3CA, and BRAF mutations.

Conclusions: Stage III and IV colon and rectal cancers share similar molecular profiles, except that there were significantly more BRAF mutations in colon cancers compared with rectal cancers.
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http://dx.doi.org/10.1016/j.amjsurg.2013.01.029DOI Listing
May 2013

Surgeon leadership enables development of a colorectal cancer biorepository.

Am J Surg 2013 May;205(5):563-5; discussion 565

Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mailcode L223A, Portland, OR 97239, USA.

Background: We hypothesized that surgeons can improve the collection of all necessary elements (tissue and clinical data) needed to build a complete, robust research biorepository.

Methods: All colorectal cancer patients treated at a university medical center and its affiliates were eligible for inclusion. Data were collected from an 18-page personal and family health questionnaire, a prospectively maintained clinical database, and molecular testing. Tissues included serum, plasma and peripheral blood mononuclear cells, and tumor and normal tissue. We compared 2 groups: the surgeon-referred group and the other clinician-referred group. The primary outcome was the complete collection of data (ie, preoperative/staging clinical data, blood samples, and tissue collection). Statistical analysis was performed using the Student t test.

Results: Since 2006, 452 patients were approached, and 430 (95%) have been enrolled. Of these, 124 were referred by their surgeon, and 306 were consented in a clinic or over the telephone. Of patients referred by their surgeon, tumor tissue, blood samples, and preoperative/staging clinical data were obtained in 119 patients; conversely, in patients referred by oncologists or other clinicians, only 133 patients had complete data (96% vs 43.5%, P < .05). A total of 257 tissue samples were obtained from all patients. Additional testing has been performed on 228 specimens including immunohistochemistry, microsatellite testing, and genotype mutational analysis.

Conclusions: Surgeon-directed enrollment in a biorepository improves the ability to collect blood and tissue samples. Surgeons should take a leadership role in the development of tumor biorepositories.
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http://dx.doi.org/10.1016/j.amjsurg.2013.01.020DOI Listing
May 2013

Use and outcomes of emergent laparoscopic resection for acute diverticulitis.

Am J Surg 2012 May 22;203(5):639-643. Epub 2012 Mar 22.

Department of Surgery, Oregon Health & Science University, Mail Code L223, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098, USA. Electronic address:

Background: The use and outcomes of laparoscopic sigmoid resection during emergency admissions for diverticulitis are unknown.

Methods: The Nationwide Inpatient Sample was queried for colorectal resections performed for diverticulitis during emergent hospital admissions (2003-2007). Univariate and multivariate analyses including patient, hospital, and outcome variables were performed.

Results: A national estimate of 67,645 resections (4% laparoscopic) was evaluated. The rate of conversion to open operation was 55%. Ostomies were created in 66% of patients, 67% open and 41% laparoscopic. Laparoscopy was not a predictor of mortality (odds ratio [OR] =.70; confidence interval [CI], .32-1.53). Laparoscopy predicted routine discharge (OR = 1.31; CI, 1.06-1.63) and a decreased length of stay (absolute days = -.78; CI, -1.19 to -.37). There was no difference in the cost of hospitalization between the 2 groups (P = .45).

Conclusions: In acute diverticulitis, urgent laparoscopic resection decreases the length of stay. However, it is associated with a high conversion rate, no cost savings, and no difference in mortality.
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http://dx.doi.org/10.1016/j.amjsurg.2012.01.004DOI Listing
May 2012

Loss of expression of the cancer stem cell marker aldehyde dehydrogenase 1 correlates with advanced-stage colorectal cancer.

Am J Surg 2012 May 9;203(5):649-653. Epub 2012 Mar 9.

Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA; Department of Dermatology, Oregon Health and Science University, Portland, OR, USA.

Background: Colorectal cancer (CRC) progression is mediated by cancer stem cells (CSCs). We sought to determine if the expression of the CSC marker aldehyde dehydrogenase 1 (ALDH1) in CRC tumors varies by American Joint Committee on Cancer stage or correlates to clinical outcomes.

Methods: Primary and metastatic CRC samples from 96 patients were immunostained with antibodies to ALDH1 and imaged to evaluate marker expression. The percentage of ALDH1(+) cells was correlated to clinical outcomes.

Results: ALDH1 was overexpressed in CRC tumors compared with nonneoplastic tissue. Marker expression was highest in nonmetastatic tumors. The loss of expression was associated with advanced stage and metastatic disease. No significant correlation was found between ALDH1 expression and metastasis, recurrence, or survival.

Conclusions: ALDH1 was highly expressed in nonmetastatic CRC, but expression was lost with advancing stage. ALDH1 could be an effective therapeutic target in early CRC but not late-stage disease. No correlation was found between ALDH1 and disease prognosis.
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http://dx.doi.org/10.1016/j.amjsurg.2012.01.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4285581PMC
May 2012

Effect of surgical approach on 30-day mortality and morbidity after elective colectomy: a NSQIP study.

J Gastrointest Surg 2012 Jun 9;16(6):1212-7. Epub 2012 Mar 9.

Department of Surgery, Oregon Health & Science University, Portland, OR 97239-3098, USA.

Purpose: The aim of this study was to evaluate the laparoscopic approach and pre- and postoperative conditions as predictors of 30-day mortality and morbidity in elective colectomy.

Methods: Elective colectomies were identified in the 2005-2008 American College of Surgeons National Surgical Quality Improvement Program database. Multivariate logistic regression was used to model 30-day mortality and morbidity following elective colectomy. Propensity scores were calculated to decrease selection bias.

Results: During the period studied, 14,321 patients underwent open colectomy and 10,409 underwent laparoscopic colectomy. Factors that significantly influenced mortality included male gender [odds ratio (OR) 1.4, confidence interval (CI) 1.07-1.9]; age (OR 1.07, CI 1.05-1.08); comorbidities including dyspnea, ascites, congestive heart failure, dialysis, or disseminated cancer; and postoperative conditions including reintubation (OR 2.6, CI 1.6-4.0), renal failure (OR 3.8, CI 2.1-6.9), stroke (OR 6.44, CI 2.4-17.6), and septic shock (OR 13.1, CI 8.76-19.4). While laparoscopy was not independently associated with mortality, it was associated with decreased postoperative morbidity including reintubation (OR 0.74, CI 0.59-0.91), renal failure (OR 0.60, CI 0.4-0.91), septic shock (OR 0.74, CI 0.59-0.92), wound infection (OR 0.58, CI0.44-0.77), and pneumonia (OR 0.71, CI 0.59-0.86).

Conclusions: Based on this analysis, laparoscopy was associated with a decrease in 30-day postoperative morbidity for colectomy. However, after adjusting for preoperative comorbidities and postoperative morbidities, laparoscopy did not independently influence mortality after colectomy.
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http://dx.doi.org/10.1007/s11605-012-1860-3DOI Listing
June 2012