Publications by authors named "Joseph C Carmichael"

93 Publications

Evaluation of Pelvic Anastomosis by Endoscopic and Contrast Studies Prior to Ileostomy Closure: Are Both Necessary? A Single Institution Review.

Am Surg 2020 Oct;86(10):1296-1301

Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine, Orange, CA, USA.

Contrast enema is the gold standard technique for evaluating a pelvic anastomosis (PA) prior to ileostomy closure. With the increasing use of flexible endoscopic modalities, the need for contrast studies may be unnecessary. The objective of this study is to compare flexible endoscopy and contrast studies for anastomotic inspection prior to defunctioning stoma reversal. Patients with a protected PA undergoing ileostomy closure between July 2014 and June 2019 at our institution were retrospectively identified. Demographics and clinical outcomes in patients undergoing preoperative evaluation with endoscopic and/or contrast studies were analyzed. We identified 207 patients undergoing ileostomy closure. According to surgeon's preference, 91 patients underwent only flexible endoscopy (FE) and 100 patients underwent both endoscopic and contrast evaluation (FE + CE) prior to reversal. There was no significant difference in pelvic anastomotic leak (2.2% vs. 1%), anastomotic stricture (1.1% vs. 6%), pelvic abscess (2.2% vs. 3.0%), or postoperative anastomotic complications (4.4% vs. 9%) between groups FE and FE + CE ( > .05). Flexible endoscopy alone appears to be an acceptable technique for anastomotic evaluation prior to ileostomy closure. Further studies are needed to determine the effectiveness of different diagnostic modalities for pelvic anastomotic inspection.
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http://dx.doi.org/10.1177/0003134820964227DOI Listing
October 2020

A Phase IIa Trial of Metformin for Colorectal Cancer Risk Reduction among Individuals with History of Colorectal Adenomas and Elevated Body Mass Index.

Cancer Prev Res (Phila) 2020 02 9;13(2):203-212. Epub 2019 Dec 9.

Department of Medicine, University of California, Irvine, California.

Obesity is associated with risk of colorectal adenoma (CRA) and colorectal cancer. The signaling pathway activated by metformin (LKB1/AMPK/mTOR) is implicated in tumor suppression in Apc mice via metformin-induced reduction in polyp burden, increased ratio of pAMPK/AMPK, decreased pmTOR/mTOR ratio, and decreased pS6/S6 ratio in polyps. We hypothesized that metformin would affect colorectal tissue S6 among obese patients with recent history of CRA. A phase IIa clinical biomarker trial was conducted via the U.S. National Cancer Institute-Chemoprevention Consortium. Nondiabetic, obese subjects (BMI ≥30) ages 35 to 80 with recent history of CRA were included. Subjects received 12 weeks of oral metformin 1,000 mg twice every day. Rectal mucosa biopsies were obtained at baseline and end-of-treatment (EOT) endoscopy. Tissue S6 and Ki-67 immunostaining were analyzed in a blinded fashion using Histo score (Hscore) analysis. Among 32 eligible subjects, the mean baseline BMI was 34.9. Comparing EOT to baseline tissue S6 by IHC, no significant differences were observed. Mean (SD) Hscore at baseline was 1.1 (0.57) and 1.1 (0.51) at EOT; median Hscore change was 0.034 ( = 0.77). Similarly, Ki-67 levels were unaffected by the intervention. The adverse events were consistent with metformin's known side-effect profile. Among obese patients with CRA, 12 weeks of oral metformin does not reduce rectal mucosa pS6 or Ki-67 levels. Further research is needed to determine what effects metformin has on the target tissue of origin as metformin continues to be pursued as a colorectal cancer chemopreventive agent.
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http://dx.doi.org/10.1158/1940-6207.CAPR-18-0262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8025666PMC
February 2020

Improved survival with adjuvant chemotherapy in locally advanced rectal cancer patients treated with preoperative chemoradiation regardless of pathologic response.

Surg Oncol 2020 Mar 31;32:35-40. Epub 2019 Oct 31.

Department of Surgery, University of California, Irvine School of Medicine, Irvine, CA, USA. Electronic address:

Objective: The aim of this study is to examine the effect of postoperative chemotherapy on survival in patients with stage II or III rectal adenocarcinoma who undergo neoadjuvant chemoradiation (CRT) and surgical resection.

Methods: A retrospective review of the National Cancer Database (NCDB) from 2006 to 2013 was performed. Cases were analyzed based on pathologic complete response (pCR) status and use of adjuvant therapy. The Kaplan-Meier method was used to estimate overall survival probabilities.

Results: 23,045 cases were identified, of which 5832 (25.31%) achieved pCR. In the pCR group, 1513 (25.9%) received adjuvant chemotherapy, and in the non-pCR group, 5966 (34.7%) received adjuvant therapy. In the pCR group, five-year survival probability was 87% (95% CI 84%-89%) with adjuvant therapy and 81% (95% CI 79%-82%) without adjuvant therapy. In the non-pCR group, five-year survival probability was 78% (95% CI 76%-79%) with adjuvant therapy and 70% (95% CI 69%-71%) without adjuvant therapy. In the non-pCR and node-negative subgroup (ypN-), five-year survival probability was 86% (95% CI 84%-88%) with adjuvant therapy and 76% (95% CI 74%-77%) without adjuvant therapy. In the non-pCR and node-positive subgroup (ypN+), five-year survival probability was 67% (95% CI 65%-70%) with adjuvant therapy and 60% (95% CI 58%-63%) without adjuvant therapy.

Conclusions: Adjuvant chemotherapy in stage II or III rectal adenocarcinoma is associated with increased five-year survival probability regardless of pCR status. We observed similar survival outcomes among non-pCR ypN- treated with adjuvant chemotherapy compared with patients achieving pCR treated with adjuvant chemotherapy.
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http://dx.doi.org/10.1016/j.suronc.2019.10.021DOI Listing
March 2020

Ileocolic Resection for Crohn's Disease: A Minimally Invasive Approach Claims Its Place.

Am Surg 2018 Oct;84(10):1639-1644

Department of Surgery, University of California, Irvine, School of Medicine, Irvine, California, USA.

Ileocolic resection is the most common operation performed for Crohn's disease patients with terminal ileum involvement. We sought to evaluate the outcomes in Crohn's disease patients who underwent open ileocolic resection (OIC) and laparoscopic ileocolic resection (LIC) by using the ACS-NSQIP database from 2006 to 2015. Of 5670 patients, 48.3 per cent (2737) patients had OIC and 51.7 per cent (2933) had LIC. The number of LIC increased from 40 per cent in 2006 to 60.7 per cent in 2015. Moreover, the annual number of LIC surgeries has exceeded the number of OIC surgeries since 2013. Patients in the LIC group had shorter hospital length of stay compared with OIC group (6 ± 5 days 8.6 ± 8 days, < 0.01). The LIC procedure also had shorter operation time compared with OIC (148 ± 58 153 ± 76 minutes, = 0.01). Overall morbidity (15.8% 25.3%, AOR: 0.54, confidence interval (CI): 0.46-0.62, < 0.01), serious morbidity (10.9% 18%, AOR: 0.55, CI: 0.46-0.65, < 0.01), and SSI (9.9% 15.5%, AOR: 0.59, CI: 0.49-0.70, < 0.01) rates were lower in the LIC group than the OIC group. We demonstrated that in Crohn's disease patients, LIC has improved outcomes for ileocolic resection compared with OIC and has been chosen as the preferential treatment approach for most patients.
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October 2018

Surgical Intervention for Right-Side Diverticulitis: A Case-Matched Comparison with Left-Side Diverticulitis.

Am Surg 2018 Oct;84(10):1608-1612

Department of General Surgery, Arrowhead Regional Medical Center, Colton, California, USA.

Right-side diverticulitis (RSD) is an uncommon disease in Western countries. We conducted a case-matched comparison of surgically managed right-side and left-side diverticulitis (LSD) from the Southern California Kaiser Permanente database (2007-2014). Of 995 patients undergoing emergent surgery for diverticulitis, 33 RSD (3.3%) met our inclusion criteria and were matched (1:1) to LSD based on age, gender, year of diagnosis, and Hinchey class. Mean age of the RSD group was 56 ± 13.9 years, and 24.2 per cent were Asian. RSD was classified as Hinchey class III or IV in 28.1 per cent and 9.4 per cent of cases, respectively. Right hemicolectomy was performed in 87.9 per cent and laparoscopy was used in 24.2 per cent of the cases. Surgically managed RSD patients were more likely to be Asian (25% 3.1%, = 0.03) and have body mass index < 25 (31.3% 6.3%, = 0.02) compared with LSD patients. Diverting stoma was less common in the RSD (6.3% 62.5%) ( < 0.001). Hospital stay was shorter in RSD (7.6 ± 4.2 12.8 ± 9.4 days, = 0.006) and more common in the RSD group ( < 0.01). Open surgery (90.6% 71.9%) and postoperative complications (37.5% 25%) were more common in the LSD group, but that was not statistically significant ( > 0.05). Surgery for complicated RSD was associated with shorter hospital stay and decreased likelihood of diverting ostomy.
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October 2018

Laparoscopic loop ileostomy reversal with intracorporeal anastomosis is associated with shorter length of stay without increased direct cost.

Surg Endosc 2019 02 25;33(2):644-650. Epub 2018 Oct 25.

Department of Surgery, University of California Irvine School of Medicine, Irvine, CA, USA.

Background: Laparoscopic ileostomy closure with intracorporeal anastomosis offers potential advantages over open reversal with extracorporeal anastomosis, including earlier return of bowel function and reduced postoperative pain. In this study, we aim to compare the outcome and cost of laparoscopic ileostomy reversal (utilizing either intracorporeal or extracorporeal anastomosis) with open ileostomy reversal.

Methods: A retrospective review of sequential patients undergoing elective loop ileostomy reversal between 2013 and 2016 at a single, high-volume institution was performed. Patients were stratified on the basis of operative approach: open reversal, laparoscopic-assisted reversal with extracorporeal anastomosis (LE), and laparoscopic reversal with intracorporeal anastomosis (LI). Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes.

Results: Of 132 sequential cases of loop ileostomy reversal, 50 (38%) underwent open, 49 (37%) underwent LE, and 33 (22%) underwent LI. Demographic data and preoperative comorbidities were similar between the three cohorts. Median length of stay was significantly shorter for LI (52.1 h, p < 0.05) compared to open (69.0 h) and LE (69.6 h). After risk-adjusted analysis, length of stay was significant shorter in LI compared to LE (GM 0.78, 95% CI 0.64-0.93, p < 0.01) and open reversal (GM 0.78, 95% CI 0.66-0.93, p < 0.01). Risk-adjusted 30-day morbidity rates were similar for LI compared to LE (OR 0.43, 95% CI 0.081-2.33, p = 0.33) and open reversal (OR 0.53, 95% CI 0.09-3.125, p = 0.48). Median in-hospital direct cost was similar for LI ($6575.00), LE ($6722.50), and open reversal ($6181.00).

Conclusion: Laparoscopic ileostomy reversal with intracorporeal anastomosis was associated with shorter length of stay without increased overall direct cost. The technique of laparoscopic ileostomy reversal warrants continued study in a randomized clinical trial.
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http://dx.doi.org/10.1007/s00464-018-6518-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6724549PMC
February 2019

Intracorporeal versus extracorporeal anastomosis for minimally invasive right colectomy: A multi-center propensity score-matched comparison of outcomes.

PLoS One 2018 24;13(10):e0206277. Epub 2018 Oct 24.

Department of Surgery, Division of Colon and Rectal Surgery, University of California Irvine, Irvine, California, United States of America.

Background: The primary objective of this study was to retrospectively compare short-term outcomes of intracorporeal versus extracorporeal anastomosis for minimally invasive laparoscopic and robotic-assisted right colectomies for benign and malignant disease. Recent studies suggest potential short-term outcomes advantages for the intracorporeal anastomosis technique.

Methods: This is a multicenter retrospective propensity score-matched comparison of intracorporeal and extracorporeal anastomosis techniques for laparoscopic and robotic-assisted right colectomy between January 11, 2010, and July 21, 2016.

Results: After propensity score-matching, there were a total of 1029 minimal invasive surgery cases for analysis-379 right colectomies (335 robotic-assisted and 44 laparoscopic) done with an intracorporeal anastomosis and 650 right colectomies (253 robotic-assisted and 397 laparoscopic) done with an extracorporeal anastomosis. There were no significant differences in any preoperative patient characteristics between groups. The minimally invasive intracorporeal anastomosis group had significantly longer operative times (p<0.0001), lower conversion to open rate (p = 0.01), shorter hospital length of stay (p = 0.02) and lower complication rate from after discharge to 30-days (p = 0.04) than the extracorporeal anastomosis group.

Conclusions: This comparison shows several clinical outcomes advantages for the intracorporeal anastomosis technique in minimally invasive right colectomy. These data may guide future refinements in minimally invasive training techniques and help surgeons choose among different minimally invasive options.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206277PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200279PMC
April 2019

Association of Compensation From the Surgical and Medical Device Industry to Physicians and Self-declared Conflict of Interest.

JAMA Surg 2018 11;153(11):997-1002

Department of Surgery, University of California, Irvine, School of Medicine, Orange.

Importance: Surgical and medical device manufacturers have a cooperative relationship with clinicians. When evaluating published works, one should assess the integrity and academic credentials of the authors, who serve as putative experts. A relationship with a relevant manufacturer may increase the potential risk for bias in relevant studies.

Objective: To characterize the association of industrial payments by device manufacturers, self-declared conflict of interest (COI), and relevance of publications among physicians receiving the highest compensation.

Design, Setting, And Participants: This population-based bibliometric analysis identified 10 surgical and medical device manufacturing companies and the 10 physicians receiving the highest compensation from each company using the 2015 Open Payments Database (OPD) general payments data. For each of the 100 physicians, the total amount of general payments, number of payments, institution type, and academic rank were recorded. Royalty or license payments were excluded. A search of PubMed identified articles published by each physician from January 1 through December 31, 2016, and their associated COI declaration. Scopus was used to identify bibliometric data reported as the h index (number of papers by a researcher with at least h citations each).

Main Outcomes And Measures: Discrepancy between self-declared COI and industry payments.

Results: The 100 physicians included in the sample population (88% men) were paid a total of $12 446 969, with a median payment of $95 993. Fifty physicians (50.0%) were faculty at academic institutions. The mean (SD) h index was 18 (18; range, 0-75) for the authors. In 2016, 412 articles were published by these physicians, with a mean (SD) of 4 (6) publications (range, 0-25) and median of 1 (36 physicians had no publications). Of these articles, 225 (54.6%) were relevant to the general payments received by the authors. Only in 84 of the 225 relevant publications (37.3%) was the potential COI declared by the authors.

Conclusions And Relevance: A high level of inconsistency was found between self-declared COI and the OPD among the physicians receiving the highest industry payments. Therefore, a policy of full disclosure for all publications, regardless of relevance, is proposed. No statistically significant association was demonstrated between academic rank or productivity and industrial payments.
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http://dx.doi.org/10.1001/jamasurg.2018.2576DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583703PMC
November 2018

Oncofertility in the setting of advanced cervical cancer - A case report.

Gynecol Oncol Rep 2018 May 2;24:27-29. Epub 2018 Mar 2.

Department of Obstetrics & Gynecology, University of California, Irvine 333 City Blvd, West, Suite 1400, Orange, CA 92868, United States.

Objective: To consider fertility options in women with advanced cervical cancer.

Design: Case report.

Setting: Large tertiary care center.

Patient: A 30-year-old nulligravida woman diagnosed with FIGO Stage IB squamous cell carcinoma of the cervix that had metastasized to a pelvic lymph node.

Interventions: Robotic radical trachelectomy with pelvic lymphadenectomy and cerclage placement, followed by ovarian stimulation with oocyte retrieval and in vitro fertilization. Subsequent therapy included adjuvant chemoradiation and embryo transfer to a surrogate mother.

Main Outcome Measures: Cervical cancer remission, live birth from surrogate pregnancy.

Results: 33-year-old woman in her third year of remission from advanced cervical cancer with healthy twin girls.

Conclusions: Fertility options may exist for patients even in the setting of metastatic cervical cancer. Early involvement of a reproductive endocrinologist is imperative. This case emphasizes the importance of cross-specialty communication.
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http://dx.doi.org/10.1016/j.gore.2018.03.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5966584PMC
May 2018

Consensus Statement of Definitions for Anorectal Physiology Testing and Pelvic Floor Terminology (Revised).

Dis Colon Rectum 2018 Apr;61(4):421-427

Prepared on behalf of the Pelvic Floor Disorders Committee and 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.0000000000001070DOI Listing
April 2018

The Growing Utilization of Laparoscopy in Emergent Colonic Disease.

Am Surg 2017 Oct;83(10):1068-1073

Department of Surgery, University of California, Irvine School of Medicine, Irvine, California, USA.

Emergent colonic disease has traditionally been managed with open procedures. Evaluation of recent trends suggests a shift toward minimally invasive techniques in this disease setting. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2014 was used to examine clinical data from patients who emergently underwent open colectomy (OC) and laparoscopic colectomy (LC). Multivariate regression was utilized to analyze preoperative characteristics and determine risk-adjusted outcomes with intent-to-treat and as-treated approach. Of 10,018 patients with emergent colonic operation, 90 per cent (9023) underwent OC whereas 10 per cent (995) underwent LC. Laparoscopic utilization increased annually, with LC composing 10.9 per cent of emergent colonic operations in 2014 compared with 9.3 per cent in 2012. Compared with LC, patients treated with OC had higher rates of overall morbidity (odds ratio 2.01, 95% confidence interval 1.74-2.34, P < 0.01) and 30-day mortality (odds ratio 1.79, 95% confidence interval 1.30-2.46, P < 0.01). Subset analysis of emergent patients without preoperative septic shock revealed consistent benefits with laparoscopy in overall morbidity, 30-day mortality, ileus, and surgical site infection. In select patients with hemodynamic stability, emergent LC appears to be a safe and beneficial operation. This study reflects the growing preference and utilization of minimally invasive techniques in emergent colonic operations.
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October 2017

Authors Reply.

Dis Colon Rectum 2018 02;61(2):e14-e15

Orange, California Cleveland, Ohio.

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http://dx.doi.org/10.1097/DCR.0000000000000993DOI Listing
February 2018

An endoscopic mucosal grading system is predictive of leak in stapled rectal anastomoses.

Surg Endosc 2018 04 15;32(4):1769-1775. Epub 2017 Sep 15.

Department of Surgery, University of California, Irvine, 333 City Blvd W. Suite 850, Orange, CA, 92868, USA.

Background: Anastomotic leak is a devastating postoperative complication following rectal anastomoses associated with significant clinical and oncological implications. As a result, there is a need for novel intraoperative methods that will help predict anastomotic leak.

Methods: From 2011 to 2014, patient undergoing rectal anastomoses by colorectal surgeons at our institution underwent prospective application of intraoperative flexible endoscopy with mucosal grading. Retrospective review of patient medical records was performed. After creation of the colorectal anastomosis, application of a three-tier endoscopic mucosal grading system occurred. Grade 1 was defined as circumferentially normal appearing peri-anastomotic mucosa. Grade 2 was defined as ischemia or congestion involving <30% of either the colon or rectal mucosa. Grade 3 was defined as ischemia or congestion involving >30% of the colon or rectal mucosa or ischemia/congestion involving both sides of the staple line.

Results: From 2011 to 2014, a total of 106 patients were reviewed. Grade 1 anastomoses were created in 92 (86.7%) patients and Grade 2 anastomoses were created in 10 (9.4%) patients. All 4 (3.8%) Grade 3 patients underwent immediate intraoperative anastomosis takedown and re-creation, with subsequent re-classification as Grade 1. Demographic and comorbidity data were similar between Grade 1 and Grade 2 patients. Anastomotic leak rate for the entire cohort was 12.2%. Grade 1 patients demonstrated a leak rate of 9.4% (9/96) and Grade 2 patients demonstrated a leak rate of 40% (4/10). Multivariate logistic regression associated Grade 2 classification with an increased risk of anastomotic leak (OR 4.09, 95% CI 1.21-13.63, P = 0.023).

Conclusion: Endoscopic mucosal grading is a feasible intraoperative technique that has a role following creation of a rectal anastomosis. Identification of a Grade 2 or Grade 3 anastomosis should provoke strong consideration for immediate intraoperative revision.
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http://dx.doi.org/10.1007/s00464-017-5860-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6282754PMC
April 2018

Respiratory complications after colonic procedures in chronic obstructive pulmonary disease: does laparoscopy offer a benefit?

Surg Endosc 2018 03 15;32(3):1280-1285. Epub 2017 Aug 15.

Department of Surgery, University of California, Irvine , 333 City Blvd. W. Ste. 850, Orange, CA, 92868, USA.

Background: Patients with severe chronic obstructive pulmonary disease (COPD) are at a higher risk for postoperative respiratory complications. Despite the benefits of a minimally invasive approach, laparoscopic pneumoperitoneum can substantially reduce functional residual capacity and raise alveolar dead space, potentially increasing the risk of respiratory failure which may be poorly tolerated by COPD patients. This raises controversy as to whether open techniques should be preferentially employed in this population.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011 to 2014 was used to examine the clinical data from patients with COPD who electively underwent laparoscopic and open colectomy. Patients defined as having COPD demonstrated either functional disability, chronic use of bronchodilators, prior COPD-related hospitalization, or reduced forced expiratory reserve volumes on lung testing (FEV1 <75%). Demographic data and preoperative characteristics were compared. Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes.

Results: Of the 4397 patients with COPD, 53.8% underwent laparoscopic colectomy (LC) while 46.2% underwent open colectomy (OC). The LC and OC groups were similar with respect to demographic data and preoperative comorbidities. Equivalent frequencies of exertional dyspnea (LC 35.4 vs OC 37.7%, P = 0.11) were noted. After multivariate risk adjustment, OC demonstrated an increased rate of overall respiratory complications including pneumonia, reintubation, and prolonged ventilator dependency when compared to LC (OR 1.60, 95% CI 1.30-1.98, P < 0.01). OC was associated with longer length of stay (10 ± 8 vs. 6.7 ± 7 days, P < 0.01) and higher readmission (OR 1.36, 95% CI 1.09-1.68, P < 0.01) compared to LC.

Conclusion: Despite the potential risks of laparoscopic pneumoperitoneum in the susceptible COPD population, a minimally invasive approach was associated with lower risk of postoperative respiratory complications, shorter length of stay, and decrease in postoperative morbidity.
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http://dx.doi.org/10.1007/s00464-017-5805-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281393PMC
March 2018

Randomized Clinical Trial of Epidural Compared with Conventional Analgesia after Minimally Invasive Colorectal Surgery.

J Am Coll Surg 2017 Nov 3;225(5):622-630. Epub 2017 Aug 3.

Department of Surgery, School of Medicine, University of California, Irvine, CA. Electronic address:

Background: The effectiveness of thoracic epidural analgesia (EA) vs conventional IV analgesia (IA) after minimally invasive surgery is still unproven. We designed a randomized controlled trial comparing EA with IA after minimally invasive colorectal surgery.

Study Design: A total of 87 patients who underwent minimally invasive colorectal procedures at a single institution between 2011 and 2014 were enrolled. Eight patients were excluded and 38 were randomized to EA and 41 to IA. Pain was assessed with the Visual Analogue Scale and quality of life with the Overall Benefit of Analgesia Score daily until discharge.

Results: Mean age was 57 ± 14 years, 43% of patients were female, and mean BMI was 28.6 ± 6 kg/m. The 2 groups were similar in demographic characteristics and distribution of diagnoses and procedures. Epidural analgesia had a higher incidence of hypotensive systolic blood pressure (<90 mmHg) episodes (9 vs 2; p < 0.05) and a trend toward longer Foley catheter duration (3 ± 2 days vs 2 ± 4 days; p > 0.05). Epidural and IA had equivalent mean lengths of stay (4 ± 3 days vs 4 ± 3 days), daily Visual Analogue Scale scores (2.4 ± 2.0 vs 3.0 ± 2.0), and Overall Benefit of Analgesia Scores (3.2 ± 2.0 vs 3.2 ± 2.0), and similar time to start oral diet (2.8 ± 2 days vs 2.2 ± 1 days). Epidural analgesia patients used a higher total dose of narcotics (147.5 ± 192.0 mg vs 98.1 ± 112.0 mg; p > 0.05). Epidural and IV analgesia had equivalent total hospital charges ($144,991 ± $67,636 vs $141,339 ± $75,579; p > 0.05).

Conclusions: This study indicates that EA has no added clinical benefit in patients undergoing minimally invasive colorectal surgery. A trend toward higher total narcotics use and complications with EA was demonstrated.
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http://dx.doi.org/10.1016/j.jamcollsurg.2017.07.1063DOI Listing
November 2017

Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons.

Dis Colon Rectum 2017 Aug;60(8):761-784

1 Department of Surgery, University of California, Irvine School of Medicine, Irvine, California 2 Department of Surgery, Baylor University Medical Center, Dallas, Texas 3 Department of Anesthesiology, McGill University, Montreal, Quebec, Canada 4 Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 5 Department of Colorectal Surgery, Cleveland Clinic Florida, Westin, Florida 6 Department of Surgery, McGill University, Montreal, Quebec, Canada 7 Norwalk Hospital, Western Connecticut Medical Group, Norwalk, Connecticut 8 Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1097/DCR.0000000000000883DOI Listing
August 2017

Defining the Role of Minimally Invasive Proctectomy for Locally Advanced Rectal Adenocarcinoma.

Ann Surg 2017 10;266(4):574-581

Department of Surgery, University of California, Irvine School of Medicine, Irvine, CA.

Objective: National examination of open proctectomy (OP), laparoscopic proctectomy (LP), and robotic proctectomy (RP) in pathological outcomes and overall survival (OS).

Background: Surgical management for rectal adenocarcinoma is evolving towards utilization of LP and RP. However, the oncological impacts of a minimally invasive approach to rectal cancer have yet to be defined.

Methods: Retrospective review of the National Cancer Database identified patients with nonmetastatic locally advanced rectal adenocarcinoma from 2010 to 2014, who underwent neoadjuvant chemoradiation, surgical resection, and adjuvant therapy. Cases were stratified by surgical approach. Multivariate analysis was used to compare pathological outcomes. Cox proportional-hazard modeling and Kaplan-Meier analyses were used to estimate long-term OS.

Results: Of 6313 cases identified, 53.8% underwent OP, 31.8% underwent LP, and 14.3% underwent RP. Higher-volume academic/research and comprehensive community centers combined to perform 80% of laparoscopic cases and 83% of robotic cases. In an intent-to-treat model, multivariate analysis demonstrated superior circumferential margin negativity rates with LP compared with OP (odds ratio 1.34, 95% confidence interval 1.02-1.77, P = 0.036). Cox proportional-hazard modeling demonstrated a lower death hazard ratio for LP compared with OP (hazard ratio 0.81, 95% confidence interval 0.67-0.99, P = 0.037). Kaplan-Meier analysis demonstrated a 5-year OS of 81% in LP compared with 78% in RP and 76% in OP (P = 0.0198).

Conclusion: In the hands of experienced colorectal specialists treating selected patients, LP may be a valuable operative technique that is associated with oncological benefits. Further exploration of pathological outcomes and long-term survival by means of prospective randomized trials may offer more definitive conclusions regarding comparisons of open and minimally invasive technique.
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http://dx.doi.org/10.1097/SLA.0000000000002357DOI Listing
October 2017

Lymph Node Positivity in Appendiceal Adenocarcinoma: Should Size Matter?

J Am Coll Surg 2017 Jul 7;225(1):69-75. Epub 2017 Feb 7.

Department of Surgery, University of California Irvine, Irvine, CA.

Background: The management algorithm for appendiceal adenocarcinoma is not well defined. This study sought to determine whether tumor size or depth of invasion better correlates with the presence of lymph node metastases in appendiceal adenocarcinoma, and to compare these rates with colon adenocarcinoma.

Study Design: A retrospective review of the National Cancer Database was performed to identify patients with appendiceal or colonic adenocarcinoma from 2004 to 2013 who underwent surgical resection. Cases were categorized by tumor size and by T stage. Rates of lymph node metastases were examined as a function of size and T stage.

Results: A total of 3,402 appendiceal and 314,864 colonic cases were identified. For appendiceal adenocarcinoma, larger tumor size was associated with higher T stage: Pearson correlation of 0.41 (95% CI 0.408 to 0.414; p < 0.001). Lymph node metastases were present in 19.1%, 27.8%, 39.6%, 39.4%, 42.4% and 39.1% for tumor sizes <1 cm, >1 to 2 cm, >2 to 3 cm, >3 to 4 cm, >4 to 5 cm, and >5 cm, respectively. Lymph node metastases were present in 0%, 11.2%, 12.3%, 35.5%, and 40.0% for in situ, T1, T2, T3, and T4 tumors, respectively. There was no difference in the rates of lymph node metastases between appendiceal and colonic adenocarcinoma for tumor sizes <3 cm, or for in situ and T1 tumors. Rates of lymph node metastases are higher in colonic adenocarcinoma for tumor sizes >3 cm and for T2, T3, and T4 tumors (p < 0.01).

Conclusions: In appendiceal adenocarcinoma, the rate of lymph node metastases is substantial, even for small tumors. Tumor size should play no role in the decision of whether to perform a hemicolectomy. Appendectomy alone does not produce an adequate lymph node sample. Right hemicolectomy should be performed for all appendiceal adenocarcinomas.
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http://dx.doi.org/10.1016/j.jamcollsurg.2017.01.056DOI Listing
July 2017

Incidence, Risk Factors, and Trends of Motor Peripheral Nerve Injury After Colorectal Surgery: Analysis of the National Surgical Quality Improvement Program Database.

Dis Colon Rectum 2017 Mar;60(3):318-325

1 Department of General Surgery, Arrowhead Regional Medical Center, Colton, California 2 Department of General Surgery, Kaiser Permanente (Fontana) Medical Center, Fontana, California 3 Department of Biostatistics, University of California Irvine, Irvine, California 4 Division of Colon and Rectal Surgery, University of California, Irvine, Irvine, California.

Background: Motor peripheral nerve injury is a rare but serious event after colorectal surgery, and a nationwide study of this complication is lacking.

Objective: The purpose of this study was to report the incidence, trends, and risk factors of motor peripheral nerve injury during colorectal surgery.

Design: The National Surgical Quality Improvement Program database was surveyed for motor peripheral nerve injury complicating colorectal procedures. Risk factors for this complication were identified using logistic regression analysis.

Settings: The study used a national database.

Patients: Patients undergoing colorectal resection between 2005 and 2013 were included.

Main Outcome Measures: The incidence, trends, and risk factors for motor peripheral nerve injury complicating colorectal procedures were measured.

Results: We identified 186,936 colorectal cases, of which 50,470 (27%) were performed laparoscopically. Motor peripheral nerve injury occurred in 122 patients (0.065%). Injury rates declined over the study period, from 0.025% in 2006 to <0.010% in 2013 (p < 0.001). Patients with motor peripheral nerve injury were younger (mean ± SD; 54.02 ± 15.41 y vs 61.56 ± 15.95 y; p < 0.001), more likely to be obese (BMI ≥30; 43% vs 31%; p = 0.003), and more likely to have received radiotherapy (12.3% vs 4.7%; p < 0.001). Nerve injury was also associated with longer operative times (277.16 ± 169.79 min vs 176.69 ± 104.80 min; p < 0.001) and was less likely to be associated with laparoscopy (p = 0.043). Multivariate analysis revealed that increasing operative time was associated with nerve injury (OR = 1.04 (95% CI, 1.03-1.04)), whereas increasing age was associated with a protective effect (OR = 0.80 (95% CI, 0.71-0.90)).

Limitations: This study was limited by its retrospective nature.

Conclusions: Motor peripheral nerve injury during colorectal procedures is uncommon (0.065%), and its rate declined significantly over the study period. Prolonged operative time is the strongest predictor of motor peripheral nerve injury during colorectal procedures. Instituting and documenting measures to prevent nerve injury is imperative; however, special attention to this complication is necessary when surgeons contemplate long colorectal procedures.
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http://dx.doi.org/10.1097/DCR.0000000000000744DOI Listing
March 2017

Body Mass Index Significantly Impacts Outcomes of Colorectal Surgery.

Am Surg 2016 Oct;82(10):930-935

Department of Surgery, School of Medicine, University of California, Irvine, Orange, California, USA.

There are limited data regarding the association between body mass index (BMI) and colorectal surgery outcomes. We sought to evaluate the effect of BMI on short-term surgical outcomes in colon and rectal surgery patients in the United States. The American College of Surgeons National Surgery Quality Improvement Project database was used to identify all patients who underwent colon or rectal resection from 2005 to 2013. Multivariate regression analysis was used to assess the independent effect of BMI on outcomes. A total of 206,360 patients underwent colorectal resection during the study period. Of these, 3.2 per cent of patients were underweight (BMI < 18.5), 23.8 per cent patients were normal weight (18.5 ≤ BMI < 25), 26.5 per cent were overweight (25 ≤ BMI < 30), 25.2 per cent were obese (30 ≤ BMI < 40), and 5.3 per cent were morbidly obese (BMI ≥ 40). Underweight patients had longer length of stay (confidence interval: 2.70-3.49, P < 0.001) and higher mortality (adjusted odds ratio: 1.45, P < 0.01) compared with patients with a normal BMI. Morbidly obese patients had the highest overall morbidity rate compared with normal BMI patients (adjusted odds ratio: 1.53, confidence interval: 1.42-1.64, P < 0.01). BMI is associated with outcomes in colon and rectal surgery patients. Underweight and morbidly obese patients have a significantly increased risk of postsurgical complications compared with those with normal BMI.
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October 2016

Outcomes of colon resection in patients with metastatic colon cancer.

Am J Surg 2016 Aug 23;212(2):264-71. Epub 2016 Mar 23.

Department of Surgery, University of California, Irvine, School of Medicine, Irvine, 333 City Blvd West, Suite 850, Orange, CA, 92868, USA. Electronic address:

Background: Patients with advanced colorectal cancer have a high incidence of postoperative complications. We sought to identify outcomes of patients who underwent resection for colon cancer by cancer stage.

Methods: The National Surgical Quality Improvement Program database was used to evaluate all patients who underwent colon resection with a diagnosis of colon cancer from 2012 to 2014. Multivariate logistic regression analysis was performed to investigate patient outcomes by cancer stage.

Results: A total of 7,786 colon cancer patients who underwent colon resection were identified. Of these, 10.8% had metastasis at the time of operation. Patients with metastatic disease had significantly increased risks of perioperative morbidity (adjusted odds ratio [AOR]: 1.44, P = .01) and mortality (AOR: 3.72, P = .01). Patients with metastatic disease were significantly younger (AOR: .99, P < .01) had a higher American Society of Anesthesiologists score (AOR: 1.29, P < .2) and had a higher rate of emergent operation (AOR: 1.40, P < .01).

Conclusions: Overall, 10.8% of patients undergoing colectomy for colon cancer have metastatic disease. Postoperative morbidity and mortality are significantly higher than in patients with localized disease.
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http://dx.doi.org/10.1016/j.amjsurg.2016.01.025DOI Listing
August 2016

Colorectal Surgery in Patients with HIV and AIDS: Trends and Outcomes over a 10-Year Period in the USA.

J Gastrointest Surg 2016 06 3;20(6):1239-46. Epub 2016 Mar 3.

Department of Surgery, Irvine School of Medicine, University of California, Irvine, CA, USA.

Background: HIV has become a chronic disease, which may render this population more prone to developing the colorectal pathologies that typically affect older Americans.

Methods: A retrospective review of the Nationwide Inpatient Sample was performed to identify patients who underwent colon and rectal surgery from 2001 to 2010. Multivariate analysis was used to evaluate outcomes among the general population, patients with HIV, and patients with AIDS.

Results: Hospital admissions for colon and rectal procedures of patients with HIV/AIDS grew at a faster rate than all-cause admissions of patients with HIV/AIDS, with mean yearly increases of 17.8 and 2.1 %, respectively (p < 0.05). Patients with HIV/AIDS undergoing colon and rectal operations for cancer, polyps, diverticular disease, and Clostridium difficile were younger than the general population (51 vs. 65 years; p < 0.01). AIDS was independently associated with increased odds of mortality (OR 2.11; 95 % CI 1.24, 3.61), wound complications (OR 1.53; 95 % CI 1.09, 2.17), and pneumonia (OR 2.02; 95 % CI 1.33, 3.08). Risk-adjusted outcomes of colorectal surgery in patients with HIV did not differ significantly from the general population.

Conclusion: Postoperative outcomes in patients with HIV are similar to the general population, while patients with AIDS have a higher risk of mortality and certain complications.
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http://dx.doi.org/10.1007/s11605-016-3119-xDOI Listing
June 2016

Post-Hospital Discharge Venous Thromboembolism in Colorectal Surgery.

World J Surg 2016 May;40(5):1255-63

Department of Surgery, University of California, Irvine, School of Medicine, Orange, CA, USA.

Background: There are limited data regarding the criteria for prophylactic treatment of venous thromboembolism (VTE) after hospital discharge. We sought to identify risk factors of post-hospital discharge VTE events following colorectal surgery.

Methods: The NSQIP database was utilized to examine patients developed VTE after hospital discharge following colorectal surgery during 2005-2013. Multivariate analysis using logistic regression was performed to quantify risk factors of VTE after discharge.

Results: We evaluated a total of 219,477 patients underwent colorectal resections. The overall incidence of VTE was 2.1 % (4556). 33.8 % (1541) of all VTE events occurred after hospital discharge. The length of postoperative hospitalization had a strong association with post-discharge VTE, with the highest risk in patients who were hospitalized for more than 1 week after operation (AOR 9.08, P < 0.01). Other factors associated with post-discharge VTE included chronic steroid use (AOR 1.81, P < 0.01), stage 4 colorectal cancer (AOR 1.40, P = 0.03), obesity (AOR 1.37, P < 0.01), age >70 (AOR 1.21, P = 0.04), and open surgery (AOR 1.36, P < 0.01). Patients who were hospitalized for more than 1 week after an open colorectal resections had a 12 times higher risk of post-discharge VTE event compared to patients hospitalized less than 4 days after a laparoscopic resection (AOR 12.34, P < 0.01).

Conclusions: VTE is uncommon following colorectal resections; however, a significant proportion occurs after patients are discharged from the hospital (33.8 %). The length of postoperative hospitalization appears to have a strong association with post-discharge VTE. High-risk patients may benefit from continued VTE prophylaxis after discharge.
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http://dx.doi.org/10.1007/s00268-015-3361-5DOI Listing
May 2016

Laparoscopic right hemicolectomy: short- and long-term outcomes of intracorporeal versus extracorporeal anastomosis.

Surg Endosc 2016 09 29;30(9):3933-42. Epub 2015 Dec 29.

Department of Surgery, University of California, Irvine School of Medicine, 333 City Blvd. West Suite 850, Orange, CA, 92868, USA.

Background: The use of laparoscopy for right hemicolectomy has gained popularity allowing the option of a totally laparoscopic intracorporeal anastomosis (IA) for intestinal reconstruction. This technique may alleviate some of the technical limitations that a surgeon faces with a laparoscopic-assisted extracorporeal anastomosis (EA).

Methods: A retrospective chart review of 195 consecutive patients who underwent laparoscopic right hemicolectomy by four colorectal surgeons at three institutions from March 2005 to June 2014 was performed. Multivariate regression analysis was used to compare postoperative and oncologic outcomes.

Results: A total of 195 patients underwent laparoscopic right hemicolectomy over the study period, with 86 (44 %) patients receiving IA and 109 (56 %) patients receiving an EA. The most common indication for surgery in both groups was cancer: 56 (65 %) of IA cases and 57 (52 %) of EA cases. IA had a significantly higher rate of minor complications but no difference in serious complications compared to EA. Conversion to open resection was higher in EA. Using multivariate analysis to compare IA versus EA, there was no significant difference in length of stay, return of bowel function, risk of anastomotic leak, risk of intraabdominal abscess or risk of wound complications. Amongst cancer resections, there was no significant difference in the median number of lymph nodes harvested (18 LNs in IA group vs. 19 LNs in EA group, P > 0.05). There was also no significant difference in overall survival and disease-free survival at 5.7 years between the two groups.

Conclusions: IA in laparoscopic right hemicolectomy is associated with similar postoperative and oncologic outcomes compared to EA. IA may possess advantages in terms of conversion and flexibility of specimen extraction, but this is counterbalanced by a higher incidence of minor complications. These findings suggest that IA represents a valid technique in the arsenal of the experienced colorectal surgeon without compromising outcomes.
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http://dx.doi.org/10.1007/s00464-015-4704-xDOI Listing
September 2016

Early Outcome of Treatment of Chronic Mesenteric Ischemia.

Am Surg 2015 Nov;81(11):1149-56

Division of Colorectal Surgery, Department of Surgery, University of California, Irvine, School of Medicine, Orange, California, USA.

There are limited data regarding long-term outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment outcomes of CMI. The NIS database was used to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Multivariate analysis using logistic regression was performed to quantify outcomes of CMI. A total of 160,889 patients were admitted for chronic vascular insufficiency of intestine; of which 7,906 patients underwent surgical/endovascular treatment for CMI. Among patients who underwent surgery 62 per cent had endovascular treatment and 38 per cent had open vascular treatment. Need of open surgery (adjusted odds ratio (AOR): 5.13, P < 0.01) and age ≥70 years (AOR: 3.41, P < 0.01) had strong associations with mortality of patients. Open vascular treatment has higher mortality (AOR: 5.07, P < 0.01) and morbidity (AOR: 2.14, P < 0.01). However, endovascular treatment had higher risk of postoperative wound hematoma (AOR: 2.81, P < 0.01). Most patients admitted for CMI are treated with endovascular treatment. Endovascular treatment has the advantage of lower mortality and morbidity. Need to open surgery and age ≥70 years have strong associations with mortality of patients.
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November 2015

Predictive Factors of Ventilator Dependency after Colon and Rectal Surgery.

Am Surg 2015 Nov;81(11):1107-13

Department of Surgery, School of Medicine, University of California, Irvine, Orange, California, USA.

There is limited data analyzing ventilator dependency by operative diagnoses and types of the procedures performed in colorectal surgery. We sought to identify predictive factors of ventilator dependency in colorectal surgery and investigate complication rates across various colorectal procedures. The National Surgical Quality Improvement Program database was used to examine the clinical data of patients with ventilator dependency for more than 48 hours after colorectal resection during 2005-2013. Multivariate regression analysis was performed to identify predictors of ventilator dependency. A total of 219,716 patients who underwent colorectal resection were identified. The rate of ventilator dependency was 3.9 per cent. The rate varied significantly based on patient diagnosis; with the highest rate seen in patients with acute mesenteric ischemia (25.9%). The highest risk of ventilator dependency according to the patients indication of surgery, type of the procedure, and preoperative factors exist in lower gastrointestinal bleeding [adjusted odds ratio (AOR): 77.44, P < 0.01], total colectomy (AOR: 1.58, P = 0.04), and American Society of Anesthesiologists classification of three or greater (AOR: 2.52, P < 0.01). Also, serum albumin level (AOR: 0.67, P < 0.01) seems to be associated with ventilator dependency. The overall rate of ventilator dependency is 3.9 per cent in colorectal surgery. However, depending on the indication for surgery, rates can be as high as 25.9 per cent. American Society of Anesthesiologist score can predict the risk of postoperative ventilator dependency in patients undergoing colorectal surgery. Serum albumin level is reversely associated with postoperative ventilator dependency.
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November 2015
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