Publications by authors named "Jitesh A Patel"

15 Publications

  • Page 1 of 1

Update: Telehealth in Colon and Rectal Surgery.

Dis Colon Rectum 2021 Jun;64(6):642-644

Division of Colorectal Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, California.

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http://dx.doi.org/10.1097/DCR.0000000000002019DOI Listing
June 2021

Significant morbidity is associated with proximal fecal diversion among high-risk patients who undergo colectomy: A NSQIP analysis.

Am J Surg 2020 10 18;220(4):830-835. Epub 2020 May 18.

Department of Surgery, University of Kentucky Medical Center, Lexington, KY, USA; Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY, USA.

Background: The value of proximal fecal diversion for patients undergoing colectomies is an ongoing debate. Previous studies have shown a benefit in decreased anastomotic leak rates and mitigation of the morbidity of a leak, especially in high-risk populations. However, more recent data suggests increased morbidity with fecal diversion, creating a complication with an unknown degree of anastomotic leak reduction. Therefore, we aimed to determine the impact on morbidity of a diverting loop ileostomy (DLI) in patients with a high risk of anastomotic leak.

Methods: The ACS-NSQIP database was queried (via CPT code) for adult patients (age ≥18 years) who underwent a colectomy only or colectomy with ileostomy (CWI) between Jan 2013 and Dec 2016. We compared thirty-day outcomes between a 3:1 propensity-matched colectomy only group to patients who had a CWI. We used risk factors for anastomotic leak as a basis of our propensity match which included preoperative smoking, steroid use, preoperative weight loss, preoperative transfusion, hypoalbuminemia, and leukocytosis; intraoperative match variables included indication for surgery, wound class, duration of operation, primary CPT code, elective vs. emergent, and inpatient vs. outpatient surgery.

Results: We identified 39,588 patients from the NSQIP database who had a colectomy only or a CWI. The colectomy only group was older (age 63 vs 52 years p < 0.001), overweight (BMI 34 vs 26.7, p < 0.001), more likely to be diabetic (16% vs 9.5%, p < 0.001) and hypertensive (49.3% vs 31.4%). However, the CWI group had higher steroid use (36.8% vs 10%, p < 0.001), preoperative sepsis (13.2% vs 2.5%, p < 0.001), smoking rate (25.7% vs 15.4%, p < 0.001), and preoperative weight loss (12.5% vs 4.9%, p < 0.001). Our propensity analysis matched 2274 colectomy only patients and 758 CWI patients. Baseline demographics were similar between groups. While the mortality rate was similar between groups (1.5% vs 1.8%, p = 0.8), CWI patients had longer length of stay (median 8 vs 7 days, p < 0.001), higher renal injury rates (3.2% vs 0.9%, p < 0.001), higher readmission rates (18.8% vs 11%, p < 0.001) and higher overall NSQIP morbidity (44.5% vs 37.6%, p = 0.001). The anastomotic leak rate was 3.8% in the CWI group and 5.1% in the colectomy only group (p = 0.09).

Conclusions: Significant thirty-day morbidity exists with a diverting ileostomy among high-risk colectomy patients with minimal benefit in anastomotic leak rates.
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http://dx.doi.org/10.1016/j.amjsurg.2020.05.007DOI Listing
October 2020

Concordance Between Expert and Nonexpert Ratings of Condensed Video-Based Trainee Operative Performance Assessment.

J Surg Educ 2020 May - Jun;77(3):627-634. Epub 2020 Mar 20.

Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, Michigan.

Objective: We examined the impact of video editing and rater expertise in surgical resident evaluation on operative performance ratings of surgical trainees.

Design: Randomized independent review of intraoperative video.

Setting: Operative video was captured at a single, tertiary hospital in Boston, MA.

Participants: Six common general surgery procedures were video recorded of 6 attending-trainee dyads. Full-length and condensed versions (n = 12 videos) were then reviewed by 13 independent surgeon raters (5 evaluation experts, 8 nonexperts) using a crossed design. Trainee performance was rated using the Operative Performance Rating Scale, System for Improving and Measuring Procedural Learning (SIMPL) Performance scale, the Zwisch scale, and ten Cate scale. These ratings were then standardized before being compared using Bayesian mixed models with raters and videos treated as random effects.

Results: Editing had no effect on the Operative Performance Rating Scale Overall Performance (-0.10, p = 0.30), SIMPL Performance (0.13, p = 0.71), Zwisch (-0.12, p = 0.27), and ten Cate scale (-0.13, p = 0.29). Additionally, rater expertise (evaluation expert vs. nonexpert) had no effect on the same scales (-0.16 (p = 0.32), 0.18 (p = 0.74), 0.25 (p = 0.81), and 0.25 (p = 0.17).

Conclusions: There is little difference in operative performance assessment scores when raters use condensed videos or when raters who are not experts in surgical resident evaluation are used. Future validation studies of operative performance assessment scales may be facilitated by using nonexpert surgeon raters viewing videos condensed using a standardized protocol.
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http://dx.doi.org/10.1016/j.jsurg.2019.12.016DOI Listing
June 2021

Novel Technique to Reduce the Incidence of SSI after Colorectal Surgery.

Am Surg 2019 Jul;85(7):695-699

SSI is a leading cause of morbidity and increases health-care cost after colorectal operations. It is a key hospital-level patient safety indicator. Previous literature has identified perioperative risk factors associated with SSI and interventions to decrease rate of infection. The purpose of this study was to evaluate the impact of blowhole closure on the rate of superficial and deep SSI. The ACS-NSQIP database was queried for patients undergoing colectomy at the University of Kentucky from 2013 to 2016. Retrospective chart review was performed to gather demographic data and perioperative variables. Wounds left open and packed were excluded. Rates of postoperative SSI were measured between the groups. One thousand eighty-three patients undergoing elective and emergent colectomy were reviewed. Nine hundred and forty-five had closed incision and 138 had blowhole closure. Patient characteristics between the groups were well matched. Patients with a blowhole closure were more likely to have an open procedure ( = 0.037) and a higher wound class ( < 0.001). The rate of superficial and deep SSI was 9.1 per cent in patients with a closed incision and 5.1 per cent in patients with blowhole closure ( = 0.142). With adjustment for approach and wound class, blowhole closure decreased the incidence of SSI ( = 0.04). There was no significant difference in morbidity or mortality. Patients undergoing elective and emergent colectomy had decreased incidence of SSI when blowhole closure was used. Given that it does not increase resource usage and its technical ease, blowhole closure should become the standard method of surgical wound closure.
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July 2019

Impact of the Affordable Care Act on Colorectal Cancer Screening, Incidence, and Survival in Kentucky.

J Am Coll Surg 2019 04 22;228(4):342-353.e1. Epub 2019 Feb 22.

Department of Surgery, University of Kentucky Medical Center, Lexington, KY; Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY. Electronic address:

Background: Kentucky ranks first in the US in cancer incidence and mortality. Compounded by high poverty levels and a high rate of medically uninsured, cancer rates are even worse in Appalachian Kentucky. Being one of the first states to adopt the Affordable Care Act (ACA) Medicaid expansion, insurance coverage markedly increased for Kentucky residents. The purpose of our study was to determine the impact of Medicaid expansion on colorectal cancer (CRC) screening, diagnosis, and survival in Kentucky.

Study Design: The Kentucky Cabinet for Health and Family Services and the Kentucky Cancer Registry were queried for individuals (≥20 years old) undergoing CRC screening (per US Preventative Services Task Force) or diagnosed with primary invasive CRC from January 1, 2011 to December 31, 2016. Colorectal cancer screening rates, incidence, and survival were compared before (2011 to 2013) and after (2014 to 2016) ACA implementation.

Results: Colorectal cancer screening was performed in 930,176 individuals, and 11,441 new CRCs were diagnosed from 2011 to 2016. Screening for CRC increased substantially for Medicaid patients after ACA implementation (+230%, p < 0.001), with a higher increase in screening among the Appalachian (+44%) compared with the non-Appalachian (+22%, p < 0.01) population. The incidence of CRC increased after ACA implementation in individuals with Medicaid coverage (+6.7%, p < 0.001). Additionally, the proportion of early stage CRC (stage I/II) increased by 9.3% for Appalachians (p = 0.09), while there was little change for non-Appalachians (-1.5%, p = 0.60). Colorectal cancer survival was improved after ACA implementation (hazard ratio 0.73, p < 0.01), particularly in the Appalachian population with Medicaid coverage.

Conclusions: Implementation of Medicaid expansion led to a significant increase in CRC screening, CRC diagnoses, and overall survival in CRC patients with Medicaid, with an even more profound impact in the Appalachian population.
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http://dx.doi.org/10.1016/j.jamcollsurg.2018.12.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537585PMC
April 2019

Concurrent Factor V Leiden and Protein C Deficiency Presenting as Mesenteric Venous Thrombosis.

Am Surg 2016 Apr;82(4):E96-8

Department of Surgery, University of Arizona, Tucson, Arizona, USA.

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April 2016

Palliative percutaneous endoscopic gastrostomy placement for gastrointestinal cancer: Roles, goals, and complications.

World J Gastrointest Endosc 2015 Apr;7(4):364-9

Matthew Mobily, Departments of Surgery, University of Arizona, Tucson, AZ 85724, United States.

Percutaneous endoscopic gastrostomy tube placement is an invaluable tool in clinical practice that has an important role in the palliative care of patients with gastrointestinal cancer. While there is no extensive data regarding the use of this procedure in patients with gastrointestinal malignancy, inferences can be made from the available information derived from studies of similar or mixed populations. Percutaneous endoscopic gastrostomy tubes can be used to provide enteral nutrition for terminal malignancies of the upper gastrointestinal tract as well as for decompression of malignant obstructions. The rates of successful placement for cancer patients with either of these indications are high, similar to those in mixed populations. There is no conclusive evidence that the procedure will help patients reach nutritional goals for those needing alimental supplementation. However, it is effective at relieving symptoms caused by malignant obstruction. A high American Society of Anesthesiologist physical status score and an advanced tumor stage have been shown to be independent predictors of poor outcomes following placement in cancer patients. This suggests the potential for similar outcomes in the palliative care of patients with advanced stage gastrointestinal cancer who may be in relatively poor physiologic condition. However, this potential should not preclude its use in patients with terminal gastrointestinal cancer considering the high rate of successful tube placement, the possible benefits and the ultimate goal of comfort in palliative care.
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http://dx.doi.org/10.4253/wjge.v7.i4.364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4400625PMC
April 2015

Is an elective diverting colostomy warranted in patients with an endoscopically obstructing rectal cancer before neoadjuvant chemotherapy?

Dis Colon Rectum 2012 Mar;55(3):249-55

Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA.

Background: Many surgeons prefer immediate diversion in patients with endoscopically obstructed rectal cancer before starting neoadjuvant chemotherapy.

Objective: The aim of this study was to compare immediate neoadjuvant chemoradiotherapy with diversion for endoscopically obstructed rectal cancer.

Design: This study is a retrospective review of patients with rectal adenocarcinoma treated from January 2000 to December 2009. Demographic, tumor, treatment, and outcome data were obtained. Data were analyzed by the use of the Fisher exact probability test and the Student t test.

Settings: This study was conducted at a tertiary care hospital/referral center.

Patients: Included were patients with a rectal adenocarcinoma unable to be traversed endoscopically but without clinical evidence of obstruction before the initiation of neoadjuvant chemoradiotherapy. Patients with recurrent tumors or those who did not complete neoadjuvant chemoradiotherapy because of compliance were excluded.

Main Outcome Measures: The primary outcomes measured were the interval from diagnosis to neoadjuvant chemoradiotherapy initiation and resection and the incidence of complete obstruction.

Results: Eighty-five patients with endoscopically obstructed rectal cancer were identified; 16 underwent immediate diversion before neoadjuvant chemoradiotherapy (diverted group) and 69 were treated with immediate neoadjuvant chemoradiotherapy. Five patients undergoing immediate neoadjuvant chemoradiotherapy presented with bloating and distension; 2 were treated with dietary modification, and 3 (4.3%) progressed to complete obstruction following completion of neoadjuvant chemoradiotherapy and required diversion. Both groups were similar in age, tumor height, and surgical margin status. Patients undergoing diversion required a significantly greater number of permanent stomas and were associated with a higher rate of radical pelvic surgery. There was a significant delay in the initiation of neoadjuvant chemoradiotherapy (p < 0.05) and proctectomy (p < 0.001) from the time of diagnosis in the diverted group compared with the immediate neoadjuvant chemoradiotherapy group. The tumors of patients undergoing diversions were more likely to be unresectable following neoadjuvant chemoradiotherapy.

Limitations: This study was limited by its retrospective design and possible selection bias.

Conclusions: Immediate diversion is unnecessary in endoscopically obstructed rectal cancer without clinical signs of obstruction. There appears to be a relationship between immediate diversion and delay in initiation of neoadjuvant chemoradiotherapy and proctectomy. We conclude that immediate neoadjuvant chemoradiotherapy in patients with endoscopically obstructed rectal cancer is safe and feasible.
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http://dx.doi.org/10.1097/DCR.0b013e3182411a8fDOI Listing
March 2012

Perioperative management of cholelithiasis in patients presenting for laparoscopic Roux-en-Y gastric bypass: have we reached a consensus?

Am Surg 2009 Jun;75(6):470-6; discussion 476

Allegheny General Hospital, Department of Surgery, Division of Bariatric Surgery, 320 East North Avenue, Pittsburgh, PA 15212, USA.

Obesity and rapid weight loss after bariatric surgery is associated with, the development of cholelithiasis and related complications. Several algorithms have been suggested in the management of the asymptomatic gallstones in patients presenting for weight loss surgery (WLS). Charts of patients presenting for laparoscopic Roux-en-Y (LRYGB) were retrospectively reviewed. Concomitant or delayed cholecystectomies were performed for symptomatic disease at the time of or after LRYGB, respectively. A total of 1376 patients underwent LRYGB and 21.0 per cent had a history of a cholecystectomy. An additional 2.7 per cent underwent cholecystectomy. The remaining 1050 "at-risk" patients were followed for a mean of 32.3 months and 4.9 per cent underwent delayed cholecystectomy for symptomatic disease. Of these patients, 88.5 per cent presented within 2 years of LRYGB. No significant morbidities were experienced by the "at-risk" cohort. Currently, there is no consensus in the treatment of asymptomatic cholelithiasis in patients presenting for WLS. A conservative regimen of reserving cholecystectomy for symptomatic disease is safe in patients undergoing LRYGB. Subsequent cholecystectomy was required in 4.9% with the majority of these patients presenting within 2 years of LRYGB. Further investigations in the form of randomized, prospective studies are necessary to clearly define the indications for cholecystectomy at the time of WLS.
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June 2009

Endoscopic retrograde cholangiopancreatography after laparoscopic Roux-en-Y gastric bypass: a case series and review of the literature.

Am Surg 2008 Aug;74(8):689-93; discussion 693-4

Department of General Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, USA.

Endoscopic retrograde cholangiopancreatography (ERCP) has become an important tool in the diagnosis and treatment of pancreaticobiliary pathology. ERCP in patients that have undergone Roux-en-Y gastric bypass (RYGB) is particularly challenging because traditional transoral endoscopy may be limited. We present our experience with ERCP after RYGB and review the literature. In 2007 eight patients underwent ERCP after RYGB using open or laparoscopic transgastric access. After introduction of pneumoperitoneum, a total of four ports were placed. A purse-string was placed around a gastrotomy 4 to 6cm proximal to the pylorus. The endoscope was introduced through a 15 mm left-upper-quadrant port and the gastrotomy. Endoscopy was then performed. Laparoscopic gastrotomy was used in all patients that underwent a previous laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 6) and open gastrotomy was used for patients with a previous open RYGB (n = 2). Cannulation and interventions in the pancreaticobiliary tree were successful in all cases. There were no postoperative complications. Laparoscopic transgastric ERCP after LRYGB is feasible, highly successful, may be performed expeditiously, and does not seem to add significant morbidity to the procedure. The ability to perform ERCP in this patient population is critical due to their tendency to have preexisting biliary disease and to develop gallstones and the associated complications.
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August 2008

Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass.

Surg Obes Relat Dis 2008 Jan-Feb;4(1):39-45

Department of Surgery, Division of Bariatric Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA.

Background: Early reports described adverse perinatal outcomes of pregnancies after weight loss surgery (WLS), which subsequently raised concerns regarding safety. Our objective was to investigate, in a community-based, academic, tertiary care center, the safety of pregnancies after laparoscopic Roux-en-Y gastric bypass (LRYGB) and its potential effect on obesity-related perinatal complications.

Methods: The pregnancy outcomes of patients delivering infants after LRYGB at our institution were compared with those of control subjects (stratified by body mass index) who had not undergone WLS. The charts were retrospectively reviewed for demographics, delivery route, and perinatal complications.

Results: A total of 26 patients who delivered after LRYGB and 254 controls were identified. The mean interval from LRYGB to conception was 25.4 +/- 13.0 months. In general, the perinatal complications in the LRYGB patients were similar to those in the nonobese controls and lower than in the obese and severe obese controls, although statistical significance was not noted for all complications. No spontaneous abortions or stillbirths occurred in the LRYGB patients. No LRYGB patients required intravenous nutrition or hydration. The overall incidence of cesarean section in the LRYGB patients was similar to that in the obese and severely obese controls but significantly greater than that in the nonobese controls. The complication rates were similar in pregnancies occurring "early" (<12 mo) versus "late" (>18 mo) after LRYGB.

Conclusion: The results of our study have shown that pregnancy after LRYGB is safe, with an incidence of perinatal complications similar to that of nonobese patients, and lower than that of obese and severely obese patients, who had not undergone WLS. Larger studies are required to demonstrate statistically significant improvements in outcome in patients treated with WLS.
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http://dx.doi.org/10.1016/j.soard.2007.10.008DOI Listing
April 2008

Metastatic malignant melanoma of the gallbladder presenting as biliary colic: a case report and review of literature.

Am Surg 2007 Aug;73(8):833-5

Department of Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, 15212, USA.

Malignant melanoma (MM) is the most common cancer to metastasize to the gastrointestinal tract. Autopsy reports estimate that up to 15 per cent of these patients also have gallbladder metastases, and MM accounts for up to 60 per cent of metastatic lesions to the gallbladder. However, despite its prevalence, MM to the gallbladder is reported only sparingly in the literature. This discordance may be explained by the fact that these lesions are seldom symptomatic. Abdominal ultrasound remains the modality of choice in studying gallbladder pathology and has the ability to define metastatic lesions. The effect of screening for gallbladder metastases on improving survival is not well defined, and thus its role remains controversial. Cholecystectomy for melanoma metastases to the gallbladder seems to be mostly palliative, although there have been isolated reports of excellent long-term survival outcomes. The role for immunotherapy and chemotherapy in this population is not well defined, and overall prognosis is poor. Recent reports have advocated laparoscopic cholecystectomy as the treatment of choice, though there remains a concern for peritoneal port site seeding. We present the case of a 48-year-old man with MM metastatic to the gallbladder and a brief review of the literature.
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August 2007

Improvement in infertility and pregnancy outcomes after weight loss surgery.

Med Clin North Am 2007 May;91(3):515-28, xiii

Department of Surgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA.

The majority of bariatric surgical procedures are performed in young women. There is a concern about safety and outcomes of pregnancies after weight loss surgery. Pregnancy after weight loss surgery is not only safe, but is associated with more favorable outcomes in comparison to obese populations who do not undergo weight loss surgery. An interval of 2 years is recommended from surgery to pregnancy. This delay helps avoid most of the potential nutritional complications. Optimal patient care is achieved in an experienced, multidisciplinary center. Early involvement of the bariatric surgeon in evaluating abdominal pain is critical because the underlying pathology may relate to the previous weight loss surgery. Although infertility is improved after weight loss surgery, reliable modes of contraception may be limited in this population.
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http://dx.doi.org/10.1016/j.mcna.2007.01.002DOI Listing
May 2007

Pulmonary considerations in obesity and the bariatric surgical patient.

Med Clin North Am 2007 May;91(3):433-42, xi

Houston Surgical Consultants, 6560 Fannin Street, Suite 738, Houston, TX 77030, USA.

Severe obesity can be associated with significant alterations in normal cardiopulmonary physiology. The pathophysiologic effects of obesity on a patient's pulmonary function are multiple and complex. The impact of obesity on morbidity and mortality are often underestimated. Bariatric surgery has been shown to be the most effective modality of reliable and durable treatment for severe obesity. Surgical weight loss improves and, in most cases, completely resolves the pulmonary health problems associated with obesity.
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http://dx.doi.org/10.1016/j.mcna.2007.02.001DOI Listing
May 2007