Publications by authors named "Emily Steinhagen"

46 Publications

Predictors of curative-intent oncologic management among patients with stage IV rectal cancer.

Am J Surg 2021 Jul 21. Epub 2021 Jul 21.

University Hospitals Research in Surgical Outcomes and Effectiveness (UH RISES), Cleveland, OH, USA. Electronic address:

Background: Management of stage IV rectal adenocarcinoma is categorized into curative and palliative-intent strategies. The aim of this study is to determine the incidence of and associations with curative-intent treatment in stage IV rectal cancer.

Methods: The National Cancer Database from 2010 to 2016 was queried for patients with stage IV rectal adenocarcinoma and were grouped into curative-intent and non-curative management. Multivariable logistic regression was used to predict use of curative-intent management.

Results: 16,862 patients were included in this study: 4886 (30.0%) curative-intent and 11,975 (71.0%) non-curative. Multivariable regression demonstrated curative intent was associated with young age, female gender, white race, private insurance, mucinous histology and anaplastic grade.

Conclusion: Use of curative intent oncologic management among patients with stage IV rectal adenocarcinoma is influenced by age, tumor biology and location of metastatic disease. Association with gender and insurance imply the presence of disparity in the delivery of cancer care among this patient population.
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http://dx.doi.org/10.1016/j.amjsurg.2021.07.024DOI Listing
July 2021

Evaluating disparities in delivery of neoadjuvant guideline-based chemoradiation for rectal cancer: A multicenter, propensity score-weighted cohort study.

J Surg Oncol 2021 Jun 23. Epub 2021 Jun 23.

UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.

Background: Despite guideline recommendations, some patients still receive care inappropriate for their clinical stage of disease. Identification of factors that contribute to variation in guideline base care may help eradicate disparities in the treatment of early and locally advanced rectal cancer.

Methods: The American College of Surgeons National Cancer Database from 2010 to 2015 was analyzed with propensity score weighting to identify factors associated with delivery and omission of neoadjuvant guideline-based chemoradiation (GBC) for those with early and locally advanced rectal cancer.

Results: Only 74% of patients with rectal cancer received stage-appropriate neoadjuvant chemoradiation; 4544 (88%) of those with early stage disease and 8675 (68%) in locally advanced disease. Chemotherapy and radiotherapy were not planned in 27% and 34% respectively, of those who did not receive GBC. Factors associated with receipt of non-guideline-based neoadjuvant chemoradiation were age >65 years, Medicare insurance, treatment at a community facility, West-South-Central geography, having locally advanced disease, and Charlson-Deyo score >3. Receipt of ideal guideline-based neoadjuvant chemoradiation conferred a survival benefit at 5 years.

Conclusion: Patient and non-patient factors contribute to disparities in guideline-based delivery of neoadjuvant chemoradiation in the treatment of rectal cancer. Identification of these risk factors are important to help standardize care and improve survival outcomes.
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http://dx.doi.org/10.1002/jso.26572DOI Listing
June 2021

Neoadjuvant radiation above NCCN guidelines for rectal cancer is associated with age under 50 and early clinical stage.

Surg Endosc 2021 Jun 10. Epub 2021 Jun 10.

Department of Surgery, UH-RISES: University Hospitals Research in Surgical Outcomes and Effectiveness, 11100 Euclid Avenue, Cleveland, OH, USA.

Introduction: Recent data suggest patients with early-onset rectal cancer (EORC) receive neoadjuvant radiation above recommended doses without oncologic benefit. The use of excessive radiation may lead to worse outcomes and patient harm. We sought to evaluate predictors of aggressive neoadjuvant radiation (A-XRT) use in EORC patients and compare this to late-onset rectal cancer (LORC) patients.

Methods: The National Cancer Database from 2004 to 2014 was queried for rectal adenocarcinoma patients undergoing surgical resection. Patients with stage 0 or IV disease, positive margins, and incomplete data were excluded. Standard neoadjuvant radiation (S-XRT) was based upon NCCN guidelines: 25-50.4 Gray for stage II/III patients and none for stage I. Excess radiation was considered A-XRT. Patients diagnosed at age < 50 years were labeled EORC; those ≥ 50 years were LORC. Categorical data were analyzed with chi-square test. Logistic regression was used to analyze clinicodemographic associations with A-XRT.

Results: 45,403 patients were included: 7999 (17.6%) EORC and 37,404 (82.4%) LORC. Multivariable logistic regression demonstrated that A-XRT use among stage I patient was associated with male gender, age under 50, urban location, mucinous histology, and poor tumor differentiation. Among stage II and III patients, A-XRT use was associated with male gender, age under 50, higher education and income, and urban location. Cox hazards did not demonstrate a significant association of A-XRT use with survival.

Conclusion: Our data reaffirm that EORC patients more frequently receive A-XRT and that use is based on demographic features independent of tumor characteristics. Reasons for A-XRT, particularly in EORC patients, should be clarified to promote adherence to guidelines and minimize patient harm.
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http://dx.doi.org/10.1007/s00464-021-08585-wDOI Listing
June 2021

Effect of "Residents as Teachers" Workshop on Learner Perception of Trainee Teaching Skill.

J Surg Res 2021 Aug 10;264:418-424. Epub 2021 Apr 10.

University Hospitals Cleveland Medical Center, Department of General Surgery, Cleveland Ohio; University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland Ohio. Electronic address:

Background: Surgical residencies use variable structures for formal training in education. We hypothesized that a one-day workshop intervention would improve resident teaching ability measured by self-assessment and learner evaluation.

Materials And Methods: Faculty educators delivered a Residents as Teachers (RAT) workshop to general surgery residents on setting expectations, positive learning environment, difficult feedback and the 1-min preceptor model. For three months before and after the workshop, junior residents and medical students evaluated their supervising residents' teaching skill monthly using a Likert scale questionnaire. Pre- and postworkshop surveys were administered to resident participants to assess their knowledge of the material and teaching confidence. Results were analyzed using Wilcoxon rank sum tests. This study was conducted at a tertiary academic center with a large surgical residency program.

Results: Thirty-nine PGY 1-5 residents participated in the Residents as Teachers workshop and were included in the study. Pre- and post- workshop survey results demonstrated significant improvements in participants' knowledge and teaching confidence. On monthly assessments of seniors by junior residents, significant improvements were noted in three domains. Medical student ratings did not reflect significant improvements in resident teaching skill.

Conclusions: This is the first study using learner evaluation of a comprehensive surgical RAT program. Despite a significant increase in surgery residents' self-assessment following participation in an education workshop, no improvement was seen in resident teaching skill as perceived by medical students.
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http://dx.doi.org/10.1016/j.jss.2021.02.013DOI Listing
August 2021

Despite a Match Communication Code of Conduct, Applicants Continue to Be Asked Inappropriate Questions.

Dis Colon Rectum 2021 May;64(5):508-510

University Hospitals Research in Surgical Outcome & Effectiveness, Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio.

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http://dx.doi.org/10.1097/DCR.0000000000001980DOI Listing
May 2021

Intimate Partner Violence Among Surgeons: We are Not Immune.

Ann Surg 2021 03;273(3):387-392

Association of Women Surgeons, Chicago, Illinois.

Objective: The incidence and risk factors for IPV are not well-studied among surgeons. We sought to fill this gap in knowledge by surveying surgeons to estimate the incidence and identify risk factors associated with IPV.

Summary Of Background Data: An estimated 36.4% of women and 33.6% of men in the United States have experienced IPV. Risk factors include low SES, non-White ethnicity, psychiatric disorders, alcohol and drug abuse, and history of childhood abuse. Families with higher SES are not exempt from IPV, yet there is very little data examining incidence and risk factors among these populations.

Methods: An anonymous online survey targeting US-based surgeons was distributed through 4 major surgical societies. Demographics, history of abuse, and related factors were assessed. Chi-square analysis and multivariable logistic regression were utilized to evaluate for potential risk factors of IPV.

Results: Eight hundred eighty-two practicing surgeons and trainees completed the survey, of whom 536 (61%) reported experiencing some form of behavior consistent with IPV. The majority of respondents were women (74.1%, P = 0.004). Emotional abuse was most common (57.3%), followed by controlling behavior (35.6%), physical abuse (13.1%), and sexual abuse (9.6%).History of mental illness, [odds ratio (OR) 2.32, P < 0.001], alcohol use (frequent/daily OR 1.76, P = 0.035 and occasional OR 1.78, P = 0.015), childhood physical abuse (OR 1.96, P = 0.020), childhood emotional abuse (OR 1.76, P = 0.008), and female sex (OR 1.46, P = 0.022) were associated with IPV.

Conclusions: As the first national study of IPV among surgeons, this analysis demonstrates surgeons experience IPV and share similar risk factors to the general population.
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http://dx.doi.org/10.1097/SLA.0000000000004553DOI Listing
March 2021

Prophylactic Gynecologic Surgery at Time of Colectomy Benefits Women with Lynch Syndrome and Colon Cancer: A Markov Cost-Effectiveness Analysis.

Dis Colon Rectum 2020 10;63(10):1393-1402

University Hospitals Research in Surgical Outcome & Effectiveness (UH-RISES), Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio.

Background: Women with Lynch syndrome who have completed childbearing should be offered prophylactic hysterectomy and bilateral salpingo-oophorectomy for gynecologic cancer prevention. The benefit of prophylactic gynecologic surgery at the time of colon cancer resection is unclear.

Objective: This study aimed to compare the cost, quality of life, and likelihood of being alive and free from colon, endometrial, and ovarian cancer between operative choices for patients with Lynch syndrome undergoing surgery for colon cancer.

Design: A Markov decision tree spanning 40 years was constructed for a hypothetical cohort of 30-year-old women with Lynch syndrome who had been diagnosed with colon cancer. Outcomes of 6 surgical strategies were compared, including segmental or total abdominal colectomy with or without hysterectomy alone or combined with bilateral salpingo-oophorectomy.

Settings: A Markov cost-effectiveness analysis was performed at a single center.

Patients: A literature search was performed identifying studies of patients with genetically diagnosed Lynch syndrome that described cost, risk of mortality, and quality of life after colon cancer resection and prophylactic gynecologic surgery.

Main Outcome Measures: The primary outcomes measured were quality-adjusted life-years and the likelihood of being alive and free from colon, endometrial, and ovarian cancer 40 years after surgery.

Results: Women with Lynch syndrome who underwent a total abdominal colectomy and hysterectomy with bilateral salpingo-oophorectomy had the highest likelihood of being alive and cancer free. Total abdominal colectomy with hysterectomy was a close second, but yielded the largest amount of quality-adjusted life-years and lowest cost.

Limitations: This study is limited by the statistical method and quality of studies used.

Conclusions: Total abdominal colectomy with prophylactic hysterectomy at 30 years of age was the most cost-effective surgical choice in women with Lynch syndrome and colon cancer. The addition of bilateral salpingo-oophorectomy offered the highest event-free survival and lowest mortality. However, the additional morbidity of premature menopause of prophylactic salpingo-oophorectomy for younger women outweighed the benefit of ovarian cancer prevention. See Video Abstract at http://links.lww.com/DCR/B287. LA CIRUGÍA GINECOLÓGICA PROFILÁCTICA EN EL MOMENTO DE LA COLECTOMÍA BENEFICIA A LAS MUJERES CON SÍNDROME DE LYNCH Y CÁNCER DE COLON: UN ANÁLISIS DE COSTO-EFECTIVIDAD DE MARKOV: Las mujeres con síndrome de Lynch que han completado la maternidad deberían recibir histerectomía profiláctica y salpingooforectomía bilateral para la prevención del cáncer ginecológico. El beneficio de la cirugía ginecológica profiláctica en el momento de la resección del cáncer de colon no está claro.Comparar el costo, la calidad de vida y la probabilidad de estar viva y libre de cáncer de colon, endometrio y ovario entre las opciones quirúrgicas para pacientes con síndrome de Lynch sometidos a cirugía por cáncer de colon.Se construyó un árbol de decisión de Markov que abarca cuarenta años para una cohorte hipotética de mujeres de 30 años con síndrome de Lynch diagnosticadas con cáncer de colon. Se compararon los resultados de seis estrategias quirúrgicas, incluida la colectomía abdominal segmentaria o total con o sin histerectomía sola o combinada con salpingooforectomía bilateral.Se realizó un análisis de costo-efectividad de Markov en un solo centro.se realizó una búsqueda bibliográfica para identificar estudios de pacientes con síndrome de Lynch con diagnóstico genético que describieron el costo, el riesgo de mortalidad y la calidad de vida después de la resección del cáncer de colon y la cirugía ginecológica profiláctica.años de vida ajustados por calidad y probabilidad de estar vivo y libre de cáncer de colon, endometrio y ovario 40 años después de la cirugía.Las mujeres con síndrome de Lynch que se sometieron a una colectomía e histerectomía abdominal total con salpingooforectomía bilateral tuvieron la mayor probabilidad de estar vivas y libres de cáncer. La colectomía abdominal total con histerectomía fue un segundo lugar cercano, pero produjo la mayor cantidad de años de vida ajustados por calidad y el costo más bajo.Este estudio está limitado por el método estadístico y la calidad de los estudios utilizados.La colectomía abdominal total con histerectomía profiláctica a los 30 años fue la opción quirúrgica más rentable en mujeres con síndrome de Lynch y cáncer de colon. La adición de salpingooforectomía bilateral ofreció la mayor supervivencia libre de eventos y la menor mortalidad. Sin embargo, la morbilidad adicional de la menopausia prematura de la salpingooforectomía profiláctica para las mujeres más jóvenes superó el beneficio de la prevención del cáncer de ovario. Consulte Video Resumen en http://links.lww.com/DCR/B287. (Traducción-Dr. Yesenia Rojas-Khalil).
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http://dx.doi.org/10.1097/DCR.0000000000001681DOI Listing
October 2020

Population demographics in geographic proximity to hospitals with robotic platforms do not correlate with disparities in access to robotic surgery.

Surg Endosc 2021 Aug 21;35(8):4834-4839. Epub 2020 Sep 21.

Department of Surgery, UH-RISES, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, LKS 5047, Cleveland, OH, 44106, USA.

Background: Disparities in access to robotic surgery have been shown on the local, regional, and national level. This study aims to see if the location of hospitals with robotic platforms (HWR) correlates with population trends to explain the disparity in access to robotic surgery.

Methods: Hospitals with da Vinci surgical systems were identified by compiling data from the publicly available da Vinci surgeon locator website. Demographic, and economic data were compiled. Multivariate logistic regression and place-based analysis were used to determine population characteristics associated with geographic proximity to HWR.

Results: The United States has 1971 HWR (5.93 hospitals with robots per 1 million people). The states with the most HWR are Texas (203), California (175), and Florida (162). Multivariate logistic regression analysis of Texas counties determined population (OR 1.97, 95% CI 1.40-3.38) education level (OR 1.64, 95% CI 1.07-3.21), and urban designation (OR 1.15, 95% CI 1.05-1.31) remained significantly associated with HWR. When applied to a national level, population remained associated with higher numbers of HWR (R = 0.945), however level of education and urbanization were not.

Conclusions: Based on this study of population-level data, disparities in access to robotic surgery seen in prior literature cannot be explained exclusively by sociodemographic factors related to the geographic proximity of HWR. This suggests other biases are involved in the lack of robotic procedures performed among minority and underprivileged populations.
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http://dx.doi.org/10.1007/s00464-020-07961-2DOI Listing
August 2021

The impact of enteric fistulas on US hospital systems.

Am J Surg 2021 01 6;221(1):26-29. Epub 2020 Jul 6.

UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA. Electronic address:

Background: There is limited characterization of patients with enteric fistula. Our objective is to determine the incidence of the disease, and characterize demographics, healthcare costs, co-diagnoses, and procedures in this population.

Methods: The National Inpatient Sample database 2004-2014 was queried to identify patients with enteric fistula using ICD-9 code 569.81.

Results: There were 317,000 admissions with a diagnosis of enteric fistula from 2004 to 2014, accounting for 230,000 hospital days annually. Costs totaled $500 million with charges of $1.5 billion annually. Inpatient mortality is 4.1%. Patients had significant comorbidities and 3 procedures or surgical interventions per admission.

Conclusions: This descriptive study elucidates the impact of enteric fistula on patients and hospitals by characterizing incidence, clinical associations, and admission characteristics. There is significant financial impact with 28,000 admissions and $500 million dollars in annual costs. This study lays the groundwork for future research by characterizing the impact of enteric fistula.
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http://dx.doi.org/10.1016/j.amjsurg.2020.06.017DOI Listing
January 2021

Opioid Prescribing Patterns After Anorectal Surgery.

J Surg Res 2020 11 11;255:632-640. Epub 2020 Jul 11.

Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center/UH-RISES: Research in Surgical Outcomes & Effectiveness Center), Cleveland, OH. Electronic address:

Background: Anorectal procedures are frequently performed and have the potential to be particularly painful. There are no evidence-based guidelines regarding opioid prescribing after anorectal surgery and limited data on how surgeons determine opioid prescriptions after anorectal procedures. We hypothesize significant variations in prescribing practices. The aim of this study is to determine current opioid prescribing patterns after anorectal surgery.

Methods: A survey was sent to members of the American Society of Colon and Rectal Surgeons. It included demographics, opioid prescribing habits after anorectal procedures, and factors influencing prescribing. Median morphine equivalents were calculated. Respondents prescribing higher than the median for >4 procedures were considered high prescribers.

Results: 519 surveys were completed (3160 sent). 38.6% of respondents were high prescribers, and 61.4% were low prescribers. There were significant differences by years in practice (P = 0.049), hospital type (P = 0.037), region (P < 0.001), and procedures performed per month (P < 0.001). 73% prescribed a standard quantity of opioids for each procedure. The mean milligrams of ME prescribed overall was 129 (SD 82); by procedure the quantities were as follows: hemorrhoidectomy 188 (111), condyloma treatment 149 (105), fistulotomy 146 (98), advancement flap 144 (97), LIFT 140 (93), abscess drainage 107 (91), sphincterotomy 105 (85), chemodenervation 64 (34). Nearly, all (98%) surgeons used local anesthesia. 91% typically prescribed adjunctive medications. In multivariable analysis, performing <10 anorectal procedures per month or practicing in the Northeast or outside the US was associated with low prescribers. High prescribers were more likely to be in practice for >10 y, report >25% of patients request refills, or significantly consider patient satisfaction or phone calls when prescribing.

Conclusions: Opioid prescribing patterns are highly variable after anorectal procedures. Creating opioid prescribing guidelines for anorectal surgery is important to improve patient safety and quality of care.
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http://dx.doi.org/10.1016/j.jss.2020.05.098DOI Listing
November 2020

Where is the leak in the surgeon pipeline?

Am J Surg 2020 11 1;220(5):1174-1178. Epub 2020 Jul 1.

University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA. Electronic address:

Introduction: In order to care for an increasingly diverse population, the surgical workforce must improve in gender, racial, and ethnic diversity. We aim to identify deficiencies in the surgical pipeline.

Methods: Data from the United States Census, Bureau of Labor Statistics, and Association of American Medical Colleges were collected from 2004 to 2018, and evaluated for changing population over time.

Results: Women comprise 51% of the population, 32% of surgeons, and representation is increasing at a rate of 0.4% per year. 13% of the population and 6% of surgeons are black, and representation is decreasing at a rate of -0.1% per year. Hispanics represent 18% of the population, 6% of surgeons, and representation is increasing at a rate of 0.04% per year.

Conclusions: While the proportion of women and Hispanic surgeons is slowly increasing, the proportion of black surgeons is decreasing. Recruitment methods need to be focused to improve surgical workforce diversity.
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http://dx.doi.org/10.1016/j.amjsurg.2020.06.048DOI Listing
November 2020

Primary tumor location impacts survival in colorectal cancer patients after resection of liver metastases.

J Surg Oncol 2020 Jun 10. Epub 2020 Jun 10.

Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio.

Background And Objectives: Right-sided colon cancers (R-CC) are associated with worse outcomes compared to left-sided colon cancers (L-CC). We hypothesize that R-CC with synchronous liver metastases who undergo resection of primary and metastatic sites have worse survival and that survival will vary significantly among R-CC, L-CC, and rectal cancer (ReC).

Methods: The Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2016 was used to identify colorectal cancer patients with liver metastases who underwent surgical resection of both primary and metastatic disease. Survival was analyzed by multivariate Cox regression.

Results: A total of 2275 patients were included; 38% R-CC, 46% L-CC, and 16% ReC. R-CC primary tumors tended to be larger than 5 cm, higher grade, and mucinous (all P < .001). Compared to patients with R-CC, both L-CC and ReC had improved overall (HR 0.72; P < .001; HR 0.75, P = .006) and disease-specific (HR 0.71, P < .001; HR 0.73, P = .008) survival. There was no difference in survival between L-CC and ReC.

Conclusions: Patients with R-CC have significantly worse survival than L-CC or ReC. This provides additional evidence that R-CC tumors are fundamentally different from L-CC and ReC tumors. Future studies should determine factors responsible for this disparity, and identify targeted treatment based on primary tumor location.
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http://dx.doi.org/10.1002/jso.26061DOI Listing
June 2020

Institutional Outcomes Should Be a Determinant in Decision to Perform Laparoscopic Proctectomies for Rectal Cancer.

Cureus 2020 Apr 14;12(4):e7666. Epub 2020 Apr 14.

Colorectal Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA.

Purpose Minimally invasive rectal cancer (RC) resection has become common, despite recent high-profile trials failing to show non-inferiority to open proctectomy. We hypothesized that at a high-volume center, laparoscopic resection may have superior outcomes compared to those seen in ALaCaRT and ACOSOG Z6051. Methods Retrospective review of patients undergoing laparoscopic proctectomy from 2007 to 2015 for RC was performed at a high-volume center. Primary outcome was successful resection defined by negative circumferential resection margin (CRM) and distal margin (DM), and complete total mesorectal excision (TME). Results A total of 89 patients were included. Of 33 patients with TME grading, 31 (93.9%) had complete/near complete TME, and 29 (87.9%) had a "successful resection" compared with 81.7% in ACOSOG and 82% in ALaCART trials using same criteria. CRM was ≥1 mm in 87 (97.8%) of patients. Mean DM was 3.8 cm; 97.8% of patients had negative DM. Conclusion High-volume centers can achieve similar high quality RC outcomes to those demonstrated in recent trials. Institutional outcomes should determine optimal surgical technique.
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http://dx.doi.org/10.7759/cureus.7666DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7226664PMC
April 2020

Adding Boost to Standard Neoadjuvant Radiation for Rectal Cancer Improves Likelihood of Complete Response.

J Gastrointest Surg 2020 07 22;24(7):1655-1662. Epub 2020 Apr 22.

Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA.

Background: Pathologic tumor response is a prognostic factor for survival in patients with rectal cancer. Standard neoadjuvant radiation (nRT) dosing for locally advanced rectal cancer ranges from 4500 to 5400 centigray (cGy), but it is unknown if tumor regression differs as a consequence adding a boost to the tumor bed.

Methods: The National Cancer Database (NCDB) 2006-2016 was used to identify patients 18 years of age and older with clinical stage II and III rectal cancer who received pelvic nRT dosed between 4500 and 5400 cGy. Standard nRT dose (no boost, NB) and dose with boost (DWB) were defined respectively as 4500 and 5040-5400 cGy. Complete pathologic response (pCR) was defined as postoperative pathologic stage of zero. A multivariate logistic regression was performed to evaluate the association between radiation dosing and pCR.

Results: The study cohort was 28,841 patients; the majority received DWB 22,701 (78.7%), while 6140 (21.3%) received NB. pCR was achieved in 3135 (14.4%) patients. On multivariate analysis, patients who received NB were significantly less likely to have complete tumor response (OR 1.41, 95% CI 1.2-1.66, p < 0.001). Other factors significantly associated with pCR included insurance, facility type, tumor characteristics, clinical stage, and time between radiation and surgery.

Conclusions: This is the first investigation demonstrating that standard dose neoadjuvant radiation for rectal cancer was associated with a lower likelihood of pCR compared with standard dose with boost. Past studies demonstrate that rectal cancer patient survival is strongly correlated with pCR. Prospective trials should focus on examining neoadjuvant radiation dosing to evaluate if DWB improves outcomes.
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http://dx.doi.org/10.1007/s11605-020-04594-7DOI Listing
July 2020

Sarcopenia is associated with worse overall survival in patients with anal squamous cell cancer.

J Surg Oncol 2020 Jun 4;121(7):1148-1153. Epub 2020 Mar 4.

Department of Surgery, Research in Surgical Outcomes and Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, Ohio.

Background And Objectives: Sarcopenia is associated with poor long-term outcomes in many gastrointestinal cancers, but its role in anal squamous cell carcinoma (ASCC) is not defined. We hypothesized that patients with sarcopenic ASCC experience worse long-term outcomes.

Methods: A retrospective review of patients with ASCC treated at an academic medical center from 2006 to 2017 was performed. Of 104 patients with ASCC, 64 underwent PET/computed tomography before chemoradiation and were included in the analysis. The skeletal muscle index was calculated as total L3 skeletal muscle divided by height squared. Sarcopenia thresholds were 52.4 cm /m for men and 38.5 cm /m for women. Cox regression analysis was performed to assess overall and progression-free survival.

Results: Twenty-five percent of the patients were sarcopenic (n = 16). Demographics were similar between groups. There was no difference in the clinical stage or comorbidities between groups. On multivariate analysis, factors associated with worse overall survival were male gender (hazard ratio [HR] 3.7, P = .022) and sarcopenia (HR 3.6, P = .019). Male gender was associated with worse progression-free survival (HR 2.6, P = .016).

Conclusions: Sarcopenia is associated with worse overall survival in patients with anal cancer. Further studies are indicated to determine if survival can be improved with increased attention to nutritional status in sarcopenic patients.
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http://dx.doi.org/10.1002/jso.25887DOI Listing
June 2020

"Residents as Teachers" Workshop Improves Knowledge, Confidence, and Feedback Skills for General Surgery Residents.

J Surg Educ 2020 Jul - Aug;77(4):757-764. Epub 2020 Feb 11.

Case Western Reserve University School of Medicine, Cleveland, Ohio; University Hospitals Cleveland Medical Center, Cleveland, Ohio; University Hospitals Research in Surgical Outcomes and Effectiveness Center (UH-RISES), Cleveland, Ohio. Electronic address:

Objective: Surgical residents receive limited formal training in education, yet they are expected to teach medical students and one another. A "Residents as Teachers" curriculum was developed and implemented to improve residents' knowledge of educational strategies, confidence in teaching abilities, and quality of feedback given to learners.

Design: A 6-hour workshop was delivered at an academic general surgery residency program. It included 3 interactive sessions: "Teaching on the wards", "How to give and receive feedback", and "Teaching in the operating room (OR)". Pre- and postsession surveys were administered to evaluate participants' knowledge and confidence regarding teaching skills. Standard statistical analyses were used to compare pre- and postcurriculum scores.

Setting: General surgery residents at Case Western Reserve University/University Hospitals Cleveland Medical Center Program attended a 6-hour educational seminar entitled "Residents as Teachers". Three attending surgeons with expertise in surgical education administered the curriculum.

Participants: Twenty-four residents completed the course and surveys (5 PGY-5s, 6 PGY-4s, 4 PGY-3s, 5 PGY-2s, and 4 PGY-1s).

Results: On a 5-point Likert scale, residents' self-rating of teaching skills (pre = 1.8, post = 3.04, p < 0.001) and understanding of adult learning (pre = 1.88, post = 4.42, p < 0.001) improved significantly. The greatest gain was in describing effective strategies for teaching in the OR (pre = 1.75, post = 4.38, p < 0.001). Residents reported improved understanding of effective feedback characteristics (pre = 2.5, post = 4.33, p < 0.001), and felt more prepared to provide feedback to learners (pre = 2.73, post = 3.17, p = 0.01). Scores on 5 of 10 knowledge-based questions significantly improved following the intervention. All participants agreed or strongly agreed that the workshop improved the program's surgical education curriculum (mean score 4.42 of 5).

Conclusions: A "Residents as Teachers" workshop improved resident confidence in teaching and feedback skills, particularly for intraoperative instruction, and improved knowledge in the 3 specific educational domains included in the session.
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http://dx.doi.org/10.1016/j.jsurg.2020.01.010DOI Listing
June 2021

Disparities in neoadjuvant radiation dosing for treatment of rectal cancer.

Am J Surg 2020 10 13;220(4):987-992. Epub 2020 Jan 13.

Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, USA. Electronic address:

Background: Certain patients are less likely to undergo appropriate cancer treatment, worsening their overall cancer survival. The purpose of this investigation was to identify factors associated with inadequate neoadjuvant radiation for rectal cancer.

Methods: The National Cancer Database was queried for patients with locally advanced rectal cancer who received neoadjuvant radiation 2006-2014. Adequate radiation was considered to be 4,500-5,040 cGy. Demographic, hospital and clinical variables were analyzed for association with inadequate radiation.

Results: The study cohort was 34,391 patients; 1,842(5.4%) received inadequate radiation. On multivariate analysis, female gender, older age, other race, government-provided insurance, lower clinical stage and rural location correlated with inadequate radiation.

Conclusions: Women were 50% less likely than men to receive correct neoadjuvant radiation dosing. Other factors including age, race, insurance, clinical stage, geographic location and neoadjuvant chemotherapy were significantly associated with radiation dosing. These factors should be evaluated to determine if they can be modified to improve outcomes.
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http://dx.doi.org/10.1016/j.amjsurg.2020.01.016DOI Listing
October 2020

Does umbilical contamination correlate with colorectal surgery patient outcomes?

Int J Colorectal Dis 2020 Jan 28;35(1):95-100. Epub 2019 Nov 28.

Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.

Purpose: Most preoperative assessment tools to evaluate risk for postoperative complications require multiple data points to be collected and can be logistically burdensome. This study evaluated if umbilical contamination, a simple bedside assessment, correlated with surgical outcomes.

Methods: A 6-point score to measure umbilical contamination was developed and applied prospectively to patients undergoing colorectal surgery at an academic medical center.

Results: There were 200 patients enrolled (mean age 58.1 ± 14.8; 56% female). The mean BMI was 28.6 ± 7.4. Indications for surgery included colon cancer (24%), rectal cancer (18%), diverticulitis (13.5%), and Crohn's disease (12.5%). Umbilical contamination scores were 0 (23%, cleanest), 1 (26%), 2 (21%), 3 (24%), 4 (6%), and 5 (0%, dirtiest). Umbilical contamination did not correlate with preoperative functional status (p > 0.2). Umbilical contamination correlated with increased length of stay (rho = 0.19, p = 0.007) and postoperative complications (OR 1.3, 1.02-1.7, p = 0.04), but not readmission (p = 0.3) or discharge disposition (p > 0.2).

Conclusion: Sterile preparation of the abdomen is an important component of proper surgical technique and umbilical contamination correlates with increased postoperative complications.
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http://dx.doi.org/10.1007/s00384-019-03443-7DOI Listing
January 2020

Outcomes in immunosuppressed anal cancer patients.

Am J Surg 2020 01 19;219(1):88-92. Epub 2019 Aug 19.

University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA. Electronic address:

Background: Immunosuppressed patients have an increased risk of developing anal cancer, but little data exists regarding outcomes of this population.

Methods: A retrospective review of anal cancer patients at a single academic institution from 2006 to 2017 was performed.

Results: 19 (14%) of 136 anal cancer patients were immunosuppressed. Immunosuppressed patients were more likely to be hypoalbuminemic (21% vs. 6%, p = 0.025), less likely to complete chemotherapy (58% vs. 80%, p = 0.031) or exhibit a complete response to chemoradiation (57% vs. 82%, p = 0.037), and more likely to experience recurrence (53% vs. 25%, p = 0.013). Hypoalbuminemia was significantly associated with worse overall (HR 6.4, CI 2.2-19.2, p < 0.001) and progression-free (HR 4.4, CI 1.8-10.4, p < 0.001) survival.

Conclusions: Immunosuppressed patients have poor tolerance of chemotherapy and response to chemoradiation, and an increased rate of recurrence. This finding is possibly due to the relationship between immunosuppression and hypoalbuminemia, which was associated with worse overall and progression-free survival.
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http://dx.doi.org/10.1016/j.amjsurg.2019.08.011DOI Listing
January 2020

General surgery resident experience with anorectal surgery.

Am J Surg 2020 06 17;219(6):993-997. Epub 2019 Aug 17.

Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospital, Cleveland Medical Center, Cleveland, OH, USA. Electronic address:

Background: Previous studies have suggested that general surgery residents graduate with suboptimal anorectal experience. However, competence in anorectal procedures is an important part of general surgery training.

Methods: ACGME general surgery resident case logs from 1999 to 2017 were reviewed. Mean number of anorectal procedures were evaluated, comparing Period 1 (1999-2008) and Period 2 (2009-2017).

Results: Between 1999 and 2017, the mean number of all anorectal procedures performed by each general surgery resident has increased from 25.9 to 32.4 (by 25%). Between Period 1 and 2, mean numbers of total anorectal procedures, abscess drainage, fistula repair, hemorrhoidectomy, prolapse repair, other anorectal procedures all increased (p ≤ 0.01). Mean numbers of sphincterotomy/sphincteroplasty and other procedures for fecal incontinence significantly decreased (p ≤ 0.01).

Conclusions: General surgery residents have gained more experience in some anorectal procedures over time. The required number of procedures to establish competence is not well defined and should be formally evaluated.
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http://dx.doi.org/10.1016/j.amjsurg.2019.08.010DOI Listing
June 2020

Delayed Diagnosis of Anal Cancer.

J Gastrointest Surg 2020 01 16;24(1):212-217. Epub 2019 Aug 16.

University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Department of Surgery, University Hospitals, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.

Background: Recent literature has shown disparities in diagnosis and treatment of anal cancer. Common perception is that many anal cancer patients may experience a delay in diagnosis and this may contribute to poor outcomes.

Methods: Patients diagnosed with anal cancer at a single academic institution from 2006 to 2017 were retrospectively reviewed. Patients were stratified according to time from symptom onset to diagnosis and divided into three groups: diagnosed within 6 weeks, between 6 weeks and 6 months, and greater than 6 months.

Results: A total of 93 patients were included in this study. Twenty-two (23.7%) were diagnosed within 6 weeks, 48 (51.6%) between 6 weeks and 6 months, and 23 (24.7%) were diagnosed more than 6 months after the onset of symptoms. Over half (57%) of all patients were initially diagnosed with a benign condition. Stage did not vary significantly between groups. Patient diagnosed within 6 weeks had the highest rates of completion of chemotherapy (90%), radiation (95%), and complete response to chemoradiation (77%) but these did not reach statistical significance. There was no difference in recurrence, or overall survival between the groups.

Conclusions: Over half of anal cancer patients were initially misdiagnosed, and 25% were symptomatic for more than 6 months prior to diagnosis. Those patients diagnosed earlier tended to be more likely to receive complete chemoradiation therapy. We were unable to show a statistical difference in outcomes between groups. Further investigation into provider education and awareness of anal cancer is warranted to improve the care of these patients.
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http://dx.doi.org/10.1007/s11605-019-04364-0DOI Listing
January 2020

Robotic proctectomy for rectal cancer in the US: a skewed population.

Surg Endosc 2020 06 1;34(6):2651-2656. Epub 2019 Aug 1.

Department of Surgery, University Hospitals Research in Surgical Outcome & Effectiveness (UH-RISES), University Hospitals Cleveland Medical Center/Case Western Reserve University, 11100 Euclid Avenue, LKS 5047, Cleveland, OH, 44106, USA.

Background: Socioeconomic and racial differences have been associated with disparities in cancer care within the US, including disparate access to minimally invasive surgery for rectal cancer. We hypothesized that robotic approach to rectal cancer may be associated with similar disparities.

Methods: The National Cancer Database (NCDB) was used to identify patients over 18 years old with clinical stage I-III rectal adenocarcinoma who underwent a proctectomy between 2010 and 2014. Demographic and hospital factors were analyzed for association with robotic approach. Factors identified on bivariate analyses informed multivariate analysis.

Results: We identified 33,503 patients who met inclusion criteria; 3702 (11.1%) underwent robotic surgery with 7.8% conversion rate. Patients who received robotic surgery were more likely to be male, white, privately insured and with stage III cancer. They were also more likely to live in a metropolitan area, more than 25 miles away from the hospital and with a higher high school graduation rate. The treating hospital was more likely to be academic and high volume.

Conclusions: Robotic surgery is performed rarely and access to it is limited for patients who are female, black, older, non-privately insured and unable to travel to high-volume teaching institutions. The advantages of robotic surgery may not be available to all patients given disparate access to the robot. This inherent bias in access to robot may skew study populations, preventing generalizability of robotic surgery research.
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http://dx.doi.org/10.1007/s00464-019-07041-0DOI Listing
June 2020

Evaluating the Accuracy of Hemorrhoids: Comparison Among Specialties and Symptoms.

Dis Colon Rectum 2019 07;62(7):867-871

Division of Colorectal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.

Background: A large proportion of patients with anorectal complaints are referred to colorectal surgeons with the label of hemorrhoids.

Objective: The purpose of this study was to review presenting symptoms and frequency of accurate diagnosis, as well as to analyze determinants of misdiagnosis to guide educational endeavors.

Design: This was a retrospective study.

Settings: The study was conducted at a tertiary care academic center.

Patients: The charts of patients referred to a colorectal clinic with the diagnosis of hemorrhoids from January 1, 2012, to January 1, 2017, were reviewed.

Main Outcome Measures: The accuracy of the referring provider's diagnosis of hemorrhoids was measured.

Results: Review of charts identified 476 patients with the referral diagnosis of hemorrhoids. The most common presenting symptoms were bleeding (63%; n = 302), pain (48%; n = 228), and protrusion (39%; n = 185). Anal examination (ie, external inspection and/or digital internal examination) was documented in only 48%. The hemorrhoid diagnostic accuracy was 65% (n = 311). Among patients with incorrect hemorrhoid diagnoses (35%; n = 169), actual diagnosis was anal fissure (34%), skin tag (27%), and hypertrophied papilla (6%). One rectal and 2 anal carcinomas were found (0.63%). Compared with general practitioners, gastroenterologists had 86% higher odds of correct diagnosis (OR = 1.86 (95% CI, 1.10-3.10); p = 0.02), whereas the gynecologists had 68% lower odds of correct diagnosis at the time of referral (OR = 0.32 (95% CI, 0.10-0.80); p = 0.02). On multivariable analysis, referring specialty was not predictive of accurate diagnosis. Patients presenting with protrusion had 73% higher odds of accurate diagnosis (OR = 1.7 (95% CI, 1.1-2.7); p = 0.02), whereas patients presenting with pain (OR = 1.6 (95% CI, 1.1-2.5); p = 0.03) or pruritus (OR = 2.5 (95% CI, 1.2-5.0); p = 0.008) were more likely to be misdiagnosed.

Limitations: This is a retrospective study. Not all of the charts contained all data points. The number of patients may limit the power of the study to detect some differences.

Conclusions: A variety of anorectal complaints are diagnosed as hemorrhoids by providers who have initial contact with the patients. Educational programs directed toward improving physician knowledge can potentially improve diagnostic accuracy and earlier initiation of appropriate care. Presenting symptoms other than protrusion lead to higher rate of misdiagnosis by a referring physician. See Video Abstract at http://links.lww.com/DCR/A847.
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http://dx.doi.org/10.1097/DCR.0000000000001315DOI Listing
July 2019

Decline of open surgical experience for general surgery residents.

Surg Endosc 2020 02 10;34(2):967-972. Epub 2019 Jun 10.

Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA.

Background: Minimally invasive surgery is now preferred to open in many surgical procedures. This has led to changes in training to ensure skills acquisition and education in minimally invasive technique. There have been limited data regarding the effect of the number of open procedures being performed in training. The aim of this paper is to examine the relationship in trends for open and laparoscopic procedures performed by general surgery residents.

Methods: A retrospective review of the Accreditation Council for Graduate Medical Education publicly available resident case log statistical reports for the academic years from 1999-2000 to 2017-2018 was performed for laparoscopic and open anti-reflux surgery, appendectomy, colectomy, splenectomy, and inguinal hernia repair. The data were grouped by time period and compared to evaluate changes in operative patterns.

Results: The mean number for all (open and MIS) of the selected procedures increased from 159.1 in 2000 to 223.8 in 2018 (40.7%). The mean number of laparoscopic cases increased from 23.6 to 135.6 (462%), and open decreased from 135.5 to 88.2 (- 34.9%). There was a significant decrease in the average number of open procedures performed in each period among anti-reflux operations (3.4, 1.8, 1.5, 0.7, p < 0.01), appendectomy (30.7, 23.4, 13.6, 6.8, p < 0.01), and splenectomy (3.0, 2.0, 1.6, 1.4, p < 0.05); the number of open colectomies decreased significantly from Period 2 to Period 4 (46.1, 38.5, 33.4, p < 0.02). There was a significant increase in the number of laparoscopic procedures performed in each period among appendectomy (13.1, 28.3, 48.9, 58.4, all p < 0.02), colectomy (2.9, 10.1, 19.1, 23.4, all p < 0.01), and inguinal hernia repair (9.7, 14.9, 25.6, 34.1, all p < 0.01).

Conclusion: The number of open procedures performed by general surgery residents continues to decline despite an increase in total cases reported. The reduction in open surgical experience may result in surgeons who lack technical skills to safely complete open procedures.
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http://dx.doi.org/10.1007/s00464-019-06881-0DOI Listing
February 2020

A Model for a Formal Mentorship Program in Surgical Residency.

J Surg Res 2019 11 30;243:64-70. Epub 2019 May 30.

Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, Ohio. Electronic address:

Background: Mentorship is a key component in preventing burnout and attrition in surgical training, yet many residencies lack a formal program, one method used to establish successful mentor relationships. We aimed to measure the difference in resident perceptions and experience after the implementation of a mentorship program.

Methods: An anonymous survey was distributed to all general surgery residents at a single academic institution before and after implementation of a year-long mentorship program that involved assigned mentors, two social events, and recommended mentorship meetings. Responses were recorded on a five-point Likert scale.

Results: Half of respondents (n = 17, 53%) attended at least one event, and 66% (n = 21) had at least one mentor meeting. The proportion of residents who identified a faculty mentor increased from 59% to 75%. Residents with two or more mentor meetings (n = 12, 38%) were more likely to report faculty were interested in mentoring and cared about their development (3.5 versus 4.6, 3.6 versus 4.6, P < 0.001). They were more likely to identify faculty approachable for resident performance (3.8 versus 4.6, P < 0.02) and outside of work concerns (3.2 versus 4.3, P < 0.01) and were more likely to be satisfied with the amount of mentorship received (2.8 versus 4.0 P < 0.001).

Conclusions: Implementation of a formal mentorship program resulted in an improvement in resident perception of faculty involvement and support. Meeting with a mentor resulted in a significant improvement in resident perception. Implementation of a mentorship program can improve resident experience, and few interactions are needed to affect the change.
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http://dx.doi.org/10.1016/j.jss.2019.04.068DOI Listing
November 2019

Total abdominal colectomy is cost-effective in treating colorectal cancer in patients with genetically diagnosed Lynch Syndrome.

Am J Surg 2019 11 16;218(5):928-933. Epub 2019 Mar 16.

Department of Surgery, University Hospital Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA. Electronic address:

Background: Lynch syndrome (LS) has a 80% lifetime risk of developing colorectal cancer and metachronous cancer. No studies have examined the quality adjusted life expectancy after SEG or TAC for LS patients, which this study was aiming for. If TAC offers a higher quality adjusted life year (QALY) to SEG in LS patients, preoperative diagnosis of LS is critical as it alters the recommended surgical procedure.

Methods: A Markov decision tree was constructed using Treeage software to compare QALY of LS patients following SEG or TAC. Probabilities, cost, and utility were obtained from literature. Cost-effectiveness analyses were performed.

Results: TAC dominates SEG as both the life-saving and cost-saving strategy. TAC dominated SEG on QALY (17.80 vs 17.13 QALY) for a cohort of LS patients diagnosed at an average of 30 year old and followed every 2 years after initial surgery.

Conclusions: We conclude that TAC as the primary surgical option for LS patients diagnosed with Stage I-III colon cancer is cost-effective. Further cost-effectiveness study is recommended to include extra-colonic malignancies in LS patients.
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http://dx.doi.org/10.1016/j.amjsurg.2019.03.011DOI Listing
November 2019

Landing Your First Colorectal Surgery Job: How to Find It and What to Expect.

Dis Colon Rectum 2019 05;62(5):529-536

Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.

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http://dx.doi.org/10.1097/DCR.0000000000001341DOI Listing
May 2019
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