Publications by authors named "Maria Widmar"

16 Publications

  • Page 1 of 1

Clinical Calculator Based on Molecular and Clinicopathologic Characteristics Predicts Recurrence Following Resection of Stage I-III Colon Cancer.

J Clin Oncol 2021 Mar 13;39(8):911-919. Epub 2021 Jan 13.

Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY.

Purpose: Clinical calculators and nomograms have been endorsed by the American Joint Committee on Cancer (AJCC), as they provide the most individualized and accurate estimate of patient outcome. Using molecular and clinicopathologic variables, a third-generation clinical calculator was built to predict recurrence following resection of stage I-III colon cancer.

Methods: Prospectively collected data from 1,095 patients who underwent colectomy between 2007 and 2014 at Memorial Sloan Kettering Cancer Center were used to develop a clinical calculator. Discrimination was measured with concordance index, and variability in individual predictions was assessed with calibration curves. The clinical calculator was externally validated with a patient cohort from Washington University's Siteman Cancer Center in St Louis.

Results: The clinical calculator incorporated six variables: microsatellite genomic phenotype; AJCC T category; number of tumor-involved lymph nodes; presence of high-risk pathologic features such as venous, lymphatic, or perineural invasion; presence of tumor-infiltrating lymphocytes; and use of adjuvant chemotherapy. The concordance index was 0.792 (95% CI, 0.749 to 0.837) for the clinical calculator, compared with 0.708 (95% CI, 0.671 to 0.745) and 0.757 (0.715 to 0.799) for the staging schemes of the AJCC manual's 5th and 8th editions, respectively. External validation confirmed robust performance, with a concordance index of 0.738 (95% CI, 0.703 to 0.811) and calibration plots of predicted probability and observed events approaching a 45° diagonal.

Conclusion: This third-generation clinical calculator for predicting cancer recurrence following curative colectomy successfully incorporates microsatellite genomic phenotype and the presence of tumor-infiltrating lymphocytes, resulting in improved discrimination and predictive accuracy. This exemplifies an evolution of a clinical calculator to maintain relevance by incorporating emerging variables as they become validated and accepted in the oncologic community.
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http://dx.doi.org/10.1200/JCO.20.02553DOI Listing
March 2021

Quantitative assessment of tumor-infiltrating lymphocytes in mismatch repair proficient colon cancer.

Oncoimmunology 2020 11 11;9(1):1841948. Epub 2020 Nov 11.

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

Tumor infiltrating lymphocytes (TIL), which represent host adaptive response to the tumor, were first identified at scanning magnification to select areas with the highest counts on hematoxylin and eosin slides, quantitated per high-power field (HPF), and analyzed for association with recurrence-free survival (RFS) in 848 patients. Highest TIL in a single HPF was analyzed as a continuous and categorical variable, and optimal cutoff analysis was performed to predict RFS. Highest TIL count in a single HPF ranged from 0 to 45, and the optimal cutoff for TIL high vs TIL low was determined to be ≥ 3 vs < 3 with a concordance probability estimate of 0.74. In the entire cohort, 5-year RFS was 90.2% (95% CI = 83.7-94.2) in TIL high compared to 78.9% (95% CI = 74.1-82.9) in TIL low (log rank < .0001). TIL remained significant in the mismatch repair-proficient (pMMR) cohort where 5-year RFS was 94.6% (95% CI = 88.3-97.5) in TIL high compared to 77.9% (95% CI = 69.2-84.4) in TIL low ( = .008). On multivariable analysis, TIL and AJCC Stage were independently associated with RFS in the pMMR cohort. Qualitatively in the pMMR cohort, RFS in Stage II TIL high patients was similar to that in Stage I patients and RFS in Stage III TIL high was similar to that in Stage II TIL low patients. Assessment of TIL in a single HPF using standard H&E slides provides important prognostic information independent of MMR status and AJCC stage.
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http://dx.doi.org/10.1080/2162402X.2020.1841948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671050PMC
November 2020

Monitoring an Ongoing Enhanced Recovery After Surgery (ERAS) Program: Adherence Improves Clinical Outcomes in a Comparison of Three Thousand Colorectal Cases.

Clin Surg 2020 Aug 10;5. Epub 2020 Aug 10.

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

Aim: In 2014, Memorial Sloan Kettering Cancer Center was identified as an outlier for increased length of stay (LOS) after colorectal surgery. We subsequently implemented a comprehensive Enhanced Recovery After Surgery (ERAS) program in January 2016, which is continually monitored to target areas for improvement. The primary aim of this study was to evaluate the impact of a newly established ERAS program in a high-volume colorectal center over time.

Method: This was a retrospective cohort study, comparing 3000 sequential cancer patients who underwent elective colorectal surgery before and after ERAS implementation. Patients were divided into three groups (Pre-, Early, and Late ERAS). Adherence to ERAS process measures and outcomes (LOS, complications, and 30-day readmission) were compared among the three time periods.

Results: Adherence to ERAS metrics significantly increased over time, from a median of 25% Pre-ERAS to 67% Early and 75% Late ERAS ( < 0.0001). Mean LOS decreased from 5.2 days Pre-ERAS to 4.5 Early and 4.0 Late ERAS ( < 0.0001). There were no differences in rates of complications or readmissions, and patients with shorter LOS had lower readmission rates. With ERAS, the readmission rate was 4.4% for patients discharged within 3 days, versus >10% for LOS ≥5 days ( < 0.0001).

Conclusion: Initiation of an ERAS program at a high-volume colorectal center was associated with decreased LOS, without increasing morbidity. Increased ERAS adherence was associated with a further decrease in LOS. Multidisciplinary monitoring to promote protocol adherence is necessary for maintaining a safe and effective ERAS program.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643765PMC
August 2020

Confirmation of complete mesocolic excision with central vascular ligation.

Eur J Surg Oncol 2020 07 18;46(7):1386-1387. Epub 2020 Apr 18.

Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ejso.2020.04.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372914PMC
July 2020

Intracorporeal Anastomoses in Minimally Invasive Right Colectomies Are Associated With Fewer Incisional Hernias and Shorter Length of Stay.

Dis Colon Rectum 2020 05;63(5):685-692

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

Background: Intracorporeal anastomosis is associated with several short-term benefits. However, it is a technically challenging procedure with potential risk OBJECTIVE:: The purpose of this study was to investigate differences in short-term complications and long-term incisional hernia rates after robotic right colectomy with intracorporeal versus extracorporeal anastomoses and standardized extraction sites.

Design: This was a historical cohort study.

Settings: The study was conducted at a single institution.

Patients: All of the patients undergoing robotic right colectomy with intracorporeal anastomosis and a Pfannenstiel extraction site or extracorporeal anastomosis with a vertical midline extraction site from 2013 to 2017 were eligible. Exclusion criteria were conversion to laparotomy for tumor-related reasons or lack of follow-up.

Intervention: Intracorporeal or extracorporeal anastomosis was performed, based on availability of the robotic stapler and appropriate bedside assistance.

Main Outcome Measures: The primary outcome was incisional hernia, diagnosed either clinically or on postoperative imaging, and analyzed using time-to-event analysis. A Cox proportional hazards model was used for multivariable analysis. Secondary outcomes were analyzed using parametric and nonparametric tests. Statistical significance was set at p < 0.05.

Results: Of 164 patients who met all inclusion criteria, 67 had intracorporeal and 97 had extracorporeal anastomoses. Median follow-up time was similar in both groups (14 vs 15 mo; p = 0.73). The 1-year estimated incisional hernia rate was 12% for extracorporeal and 2% for intracorporeal anastomoses (p = 0.007); this difference was confirmed by multivariable modeling. The severity of postoperative complications was similar between the groups, but there was an increase in incisional infections and a shorter length of stay (1 day) for intracorporeal cases.

Limitations: The study was limited by its retrospective, single-surgeon nature.

Conclusions: Right colectomy with intracorporeal anastomosis and a Pfannenstiel extraction site may reduce the rate of incisional hernias compared with extracorporeal anastomosis with a vertical midline extraction site. The intracorporeal approach was also associated with a decreased length of stay but an increase in incisional surgical site infections. These findings have implications for healthcare use and patient-centered outcomes. See Video Abstract at http://links.lww.com/DCR/B147. ANASTOMOSIS INTRACORPÓREAS EN COLECTOMÍAS DERECHAS MÍNIMAMENTE INVASIVAS SE ASOCIAN CON MENOS HERNIAS INCISIONALES Y UNA ESTADÍA HOSPITALARIA MÁS BREVE: nastomosis intracorpórea se asocia con varios beneficios a corto plazo. Sin embargo, es un procedimiento técnicamente desafiante con riesgos potenciales.nvestigar las diferencias en las complicaciones a corto plazo y las tasas de hernia incisional a largo plazo después de la colectomía robótica derecha con anastomosis intracorpórea versus extracorpórea y sitios de extracción estandarizados.Estudio de cohorte histórico.cirujano individual, institución única.Todos los pacientes sometidos a colectomía robótica derecha con anastomosis intracorpórea y un sitio de extracción de Pfannenstiel o anastomosis extracorpórea con un sitio de extracción vertical de la línea media de 2013-2017 fueron elegibles. Los criterios de exclusión fueron la conversión a laparotomía por razones relacionadas con el tumor o la falta de seguimiento.nastomosis intracorpórea o extracorpórea, según la disponibilidad de grapadora robótica y la asistencia adecuada quirúrgica.El resultado primario fue la hernia incisional, diagnosticada clínicamente o en imágenes postoperatorias, y analizada mediante análisis de tiempo hasta el evento. Se usó un modelo de riesgos proporcionales de Cox para el análisis multivariable. Los resultados secundarios se analizaron mediante pruebas paramétricas y no paramétricas. La significación estadística se estableció en p < 0,05.De 164 pacientes que cumplieron con todos los criterios de inclusión, 67 tenían anastomosis intracorpóreas y 97 tenían anastomosis extracorpóreas. La mediana del tiempo de seguimiento fue similar en ambos grupos (14 versus 15 meses, p = 0,73). La tasa de hernia incisional estimada para un año fue del 12% para las anastomosis extracorpóreas y del 2% para las anastomosis intracorpóreas (p = 0,007); esta diferencia fue confirmada por el modelado multivariable. La gravedad de las complicaciones postoperatorias fue similar entre los grupos, pero hubo un aumento de las infecciones incisionales y una estancia más corta (un día) para los casos intracorpóreos.Retrospectiva, cirujano único.a colectomía derecha con anastomosis intracorpórea y un sitio de extracción de Pfannenstiel puede reducir la tasa de hernias incisionales en comparación con la anastomosis extracorpórea con un sitio de extracción vertical en la línea media. El enfoque intracorpóreo también se asoció con una disminución de la duración de la estadía, pero con un aumento de las infecciones del sitio quirúrgico incisional. Estos hallazgos tienen implicaciones para la utilización de recursos médicos y beneficios para pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B147. (Traducción-Dr. Adrian Ortega).
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http://dx.doi.org/10.1097/DCR.0000000000001612DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7148181PMC
May 2020

Assessment of the Value of Comorbidity Indices for Risk Adjustment in Colorectal Surgery Patients.

Ann Surg Oncol 2019 Sep 17;26(9):2797-2804. Epub 2019 Jun 17.

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

Background And Purpose: Comorbidity indices (CIs) are widely used in retrospective studies. We investigated the value of commonly used CIs in risk adjustment for postoperative complications after colorectal surgery.

Methods: Patients undergoing colectomy without stoma for colonic neoplasia at a single institution from 2009 to 2014 were included. Four CIs were calculated or obtained for each patient, using administrative data: Charlson-Deyo (CCI-D), Charlson-Romano (CCI-R), Elixhauser Comorbidity Score, and American Society of Anesthesiologists classification. Outcomes of interest in the 90-day postoperative period were any surgical complication, surgical site infection (SSI), Clavien-Dindo (CD) grade 3 or higher complication, anastomotic leak or abscess, and nonroutine discharge. Base models were created for each outcome based on significant bivariate associations. Logistic regression models were constructed for each outcome using base models alone, and each index as an additional covariate. Models were also compared using the DeLong and Clarke-Pearson method for receiver operating characteristic (ROC) curves, with the CCI-D as the reference.

Results: Overall, 1813 patients were included. Postoperative complications were reported in 756 (42%) patients. Only 9% of patients had a CD grade 3 or higher complication, and 22.8% of patients developed an SSI. Multivariable modeling showed equivalent performance of the base model and the base model augmented by the CIs for all outcomes. The ROC curves for the four indices were also similar.

Conclusions: The inclusion of CIs added little to the base models, and all CIs performed similarly well. Our study suggests that CIs do not adequately risk-adjust for complications after colorectal surgery.
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http://dx.doi.org/10.1245/s10434-019-07502-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684474PMC
September 2019

Complete mesocolic excision and central vascular ligation for right colon cancer: an introduction for abdominal radiologists.

Abdom Radiol (NY) 2019 11;44(11):3518-3526

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

Objective: To provide an overview of complete mesocolic excision, along with a review of the relevant vascular anatomy and locoregional staging concepts, for abdominal radiologists.

Results: Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer has emerged as a technique that has growing interest in surgical oncology. Specific anatomic considerations and patterns of nodal spread have thus gained clinical significance, and should be familiar to abdominal radiologists. This review article provides an overview of CME with CVL, and discusses some of the important anatomic considerations in patients with colon cancer that are relevant to radiologists.

Conclusion: Knowledge of CME with CVL and the relevant anatomic and staging considerations is important for abdominal radiologists, as this surgical technique becomes increasingly utilized.
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http://dx.doi.org/10.1007/s00261-019-02037-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7154948PMC
November 2019

Variation in the Thoroughness of Pathologic Assessment and Response Rates of Locally Advanced Rectal Cancers After Chemoradiation.

J Gastrointest Surg 2019 04 4;23(4):794-799. Epub 2019 Feb 4.

Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.

Background: Pathologic complete response (pCR) is associated with better prognosis and guides management for patients with advanced rectal cancer. Response rates vary between series for unclear reasons. We examine whether the thoroughness of pathologic assessment explains differences in pCR rates.

Methods: We retrospectively reviewed pathology reports from patients with stage II/III rectal cancer who underwent chemoradiation and resection in a prospective, multicenter trial. We utilized a novel measure for the thoroughness of pathologic assessment by dividing residual tumor size by the number of cassettes evaluated (tumor size to cassette ratio, TSCR), and evaluated whether TSCR is associated with pCR. We validated our findings using a separate cohort.

Results: From the trial cohort, 71 of 247 (29%) patients achieved pCR. The pCR rate ranged from 0 to 45% and mean TSCR ranged 0.29 to 0.87 across 12 institutions. Within each institution, a lower TSCR was associated with pCR, demonstrating a higher degree of thoroughness used for tumors that achieved pCR. Moreover, across all samples, low TSCR was independently associated with pCR on multivariable analysis. This finding was corroborated in a separate cohort of 201 tumors evaluated by five pathologists; each pathologist had a lower mean TSCR for pCR calls compared with non-pCR calls. However, the mean TSCR for an institution was not associated with its overall pCR rate.

Conclusions: Pathologists assess rectal cancers that have responded significantly to neoadjuvant therapy more thoroughly. Thoroughness does not appear to explain differences in pCR rates between institutions. Our results suggest pCR is not a sampling artifact.
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http://dx.doi.org/10.1007/s11605-019-04119-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6430657PMC
April 2019

Diverted versus undiverted restorative proctocolectomy for chronic ulcerative colitis: an analysis of long-term outcomes after pouch leak short title: outcomes after pouch leak.

Int J Colorectal Dis 2019 Apr 25;34(4):691-697. Epub 2019 Jan 25.

Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 E 98th St., 15th Floor, New York, NY, 10029, USA.

Background: The safety of undiverted restorative proctocolectomy (RPC) is debated. This study compares long-term outcomes after pouch leak in diverted and undiverted RPC patients.

Methods: Data were obtained from a prospectively maintained registry from a single surgical practice. One-stage and staged procedures with an undiverted pouch were considered undiverted pouches; all others were considered diverted pouches. The outcomes measured were pouch excision and long-term diversion defined as the need for loop ileostomy at 200 weeks after pouch creation. Regression models were used to compare outcomes.

Results: There were 317 diverted and 670 undiverted pouches, of which 378 were one-stage procedures. Pouch leaks occurred in 135 patients, 92 (13.7%) after undiverted, and 43 (13.6%) after diverted pouches. Eighty-six (64%) leaks were diagnosed within 6 months of pouch creation. Undiverted patients underwent more emergent procedures within 30 days of pouch creation (p < 0.01). Pouch excision occurred in 14 (33%) diverted patients and 13 (14%) undiverted patients (p = 0.01). Thirteen (32%) diverted patients and 18 (21%) undiverted patients (p = 0.17) had ileostomies at 200 weeks after surgery. In multivariable analyses, diverted patients had a higher risk of pouch excision (HR 3.67 p < 0.01), but similar rates of ileostomy at 200 weeks (HR 1.8, p = 0.19) compared to undiverted patients.

Conclusions: Despite a likely selection bias in which "healthier" patients undergo an undiverted pouch, our data suggest that diversion does not prevent pouch excision and the need for long-term diversion after pouch leak. These findings suggest that undiverted RPC is a safe procedure in appropriately selected patients.
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http://dx.doi.org/10.1007/s00384-019-03240-2DOI Listing
April 2019

Assessment of a Watch-and-Wait Strategy for Rectal Cancer in Patients With a Complete Response After Neoadjuvant Therapy.

JAMA Oncol 2019 Apr 11;5(4):e185896. Epub 2019 Apr 11.

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

Importance: The watch-and-wait (WW) strategy aims to spare patients with rectal cancer unnecessary resection.

Objective: To analyze the outcomes of WW among patients with rectal cancer who had a clinical complete response to neoadjuvant therapy.

Design, Setting, And Participants: This retrospective case series analysis conducted at a comprehensive cancer center in New York included patients who received a diagnosis of rectal adenocarcinoma between January 1, 2006, and January 31, 2015. The median follow-up was 43 months. Data analyses were conducted from June 1, 2016, to October 1, 2018.

Exposures: Patients had a clinical complete response after completing neoadjuvant therapy and agreed to a WW strategy of active surveillance and possible salvage surgery (n = 113), or patients underwent total mesorectal excision and were found to have a pathologic complete response (pCR) at resection (n = 136).

Main Outcomes And Measures: Kaplan-Meier estimates were used for analyses of local regrowth and 5-year rates of overall survival, disease-free survival, and disease-specific survival.

Results: Compared with the 136 patients in the pCR group, the 113 patients in the WW group were older (median [range], 67.2 [32.1-90.9] vs 57.3 [25.0-87.9] years, P < .001) with cancers closer to the anal verge (median [range] height from anal verge, 5.5 [0.0-15.0] vs 7.0 [0.0-13.0] cm). All 22 local regrowths in the WW group were detected on routine surveillance and treated by salvage surgery (20 total mesorectal excisions plus 2 transanal excisions). Pelvic control after salvage surgery was maintained in 20 of 22 patients (91%). No pelvic recurrences occurred in the pCR group. Rectal preservation was achieved in 93 of 113 patients (82%) in the WW group (91 patients with no local regrowths plus 2 patients with local regrowths salvaged with transanal excision). At 5 years, overall survival was 73% (95% CI, 60%-89%) in the WW group and 94% (95% CI, 90%-99%) in the pCR group; disease-free survival was 75% (95% CI, 62%-90%) in the WW group and 92% (95% CI, 87%-98%) in the pCR group; and disease-specific survival was 90% (95% CI, 81%-99%) in the WW group and 98% (95% CI, 95%-100%) in the pCR group. A higher rate of distant metastasis was observed among patients in the WW group who had local regrowth vs those who did not have local regrowth (36% vs 1%, P < .001).

Conclusions And Relevance: A WW strategy for select rectal cancer patients who had a clinical complete response after neoadjuvant therapy resulted in excellent rectal preservation and pelvic tumor control; however, in the WW group, worse survival was noted along with a higher incidence of distant progression in patients with local regrowth vs those without local regrowth.
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http://dx.doi.org/10.1001/jamaoncol.2018.5896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6459120PMC
April 2019

Developing a robotic colorectal cancer surgery program: understanding institutional and individual learning curves.

Surg Endosc 2017 07 4;31(7):2820-2828. Epub 2016 Nov 4.

Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.

Importance: Robotic colorectal resection continues to gain in popularity. However, limited data are available regarding how surgeons gain competency and institutions develop programs.

Objective: To determine the number of cases required for establishing a robotic colorectal cancer surgery program.

Design: Retrospective review.

Setting: Cancer center.

Patients: We reviewed 418 robotic-assisted resections for colorectal adenocarcinoma from January 1, 2009, to December 31, 2014, by surgeons at a single institution. The individual surgeon's and institutional learning curve were examined. The earliest adopter, Surgeon 1, had the highest volume. Surgeons 2-4 were later adopters. Surgeon 5 joined the group with robotic experience.

Interventions: A cumulative summation technique (CUSUM) was used to construct learning curves and define the number of cases required for the initial learning phase. Perioperative variables were analyzed across learning phases.

Main Outcome Measure: Case numbers for each stage of the learning curve.

Results: The earliest adopter, Surgeon 1, performed 203 cases. CUSUM analysis of surgeons' experience defined three learning phases, the first requiring 74 cases. Later adopters required 23-30 cases for their initial learning phase. For Surgeon 1, operative time decreased from 250 to 213.6 min from phase 1-3 (P = 0.008), with no significant changes in intraoperative complication or leak rate. For Surgeons 2-4, operative time decreased from 418 to 361.9 min across the two phases (P = 0.004). Their intraoperative complication rate decreased from 7.8 to 0 % (P = 0.03); the leak rate was not significantly different (9.1 vs. 1.5 %, P = 0.07), though it may be underpowered given the small number of events.

Conclusions: Our data suggest that establishing a robotic colorectal cancer surgery program requires approximately 75 cases. Once a program is well established, the learning curve is shorter and surgeons require fewer cases (25-30) to reach proficiency. These data suggest that the institutional learning curve extends beyond a single surgeon's learning experience.
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http://dx.doi.org/10.1007/s00464-016-5292-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5418100PMC
July 2017

Oversewing staple lines to prevent anastomotic complications in primary ileocolic resections for Crohn's disease.

J Gastrointest Surg 2015 May 14;19(5):911-6. Epub 2015 Mar 14.

Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1259, New York, NY, 10029, USA,

Background: Oversewing staple lines may be a novel way to reduce anastomotic complications after primary ileocolic resections for Crohn's disease (CD).

Study Design: This is a single-institution, non-concurrent cohort study of CD patients undergoing primary ileocolic resections (ICR) with stapled anastomoses from 2007 to 2013. Demographic and clinical characteristics were collected. Propensity scores were calculated for oversewing versus not. Postoperative outcomes within 30 days of surgery were collected. Anastomotic leak, intra-abdominal abscess, small bowel obstruction, and anastomotic bleed were considered major anastomotic complications (MACs). Multivariate analysis controlling for inverse probability weights was used to identify predictors of MACs.

Results: A total of 269 patients were included, of which 120 had undergone oversewing (OS). After controlling for propensity scores, not oversewing (NOS) and OS groups were similar in all preoperative characteristics with the exception of more laparoscopic resections and intracorporeal anastomoses in the NOS group. On univariate analysis, OS was protective against MACs (odds ratio (OR) 0.29, p < 0.01). In a multivariable model using inverse propensity weights and controlling for laparoscopic and intracorporeal approaches, oversewing remained a significant predictor of reduced MACs (OR 0.37, p < 0.001), while intracorporeal anastomoses increased their likelihood (OR 3.7, p < 0.001).

Conclusions: After controlling for clinical and surgical factors, oversewing staple lines in primary ICRs for CD is correlated with reduced MACs.
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http://dx.doi.org/10.1007/s11605-015-2792-5DOI Listing
May 2015

Small bowel adenocarcinoma in Crohn's disease.

J Gastrointest Surg 2011 May 20;15(5):797-802. Epub 2011 Feb 20.

Department of Surgery, Mount Sinai School of Medicine, One Gustave L. Levy Pl, P.O. Box 1259, New York, NY 10029, USA.

Background: An association between small bowel adenocarcinoma and Crohn's disease (CD) is well-established. We present our recent experience with this entity in order to further elucidate its clinicopathological features and update our series from 1991.

Methods: A retrospective review was undertaken of all surgical patients with small bowel adenocarcinoma and CD seen at our institution between 1993 and 2009. Follow-up was assessed until time of death or by interview with survivors. Survival was calculated based on TNM (tumor extent, lymph node status, metastases staging) staging and comparing between our current and previous series.

Results: Twenty-nine patients (ten females and 19 males) were identified and followed for a median of 2 years. The median age at onset of CD symptoms was 25, and the median age at cancer diagnosis was 55.4, for a mean interval of 25.3 years. Twenty-two cancers were ileal and five were jejunal. There were no cancers in excluded intestinal loops. Significant differences in 2-year survival were determined for: node-negative (79.3%, 95%CI 58.3-100%) versus node-positive cancers (49% %, 95%CI 20.0-78.0%), and for localized (92.3%, 95%CI 77.8-100%) versus metastatic disease (33.3%, 95%CI 6.6-60%). Overall 36-month survival was 69.3% (95%CI 51.5-87.1%) compared to 40% among those without excluded loops in our series from 1991. Sixteen patients had long periods of quiescent disease before diagnosis (7-45 years), and 16 required surgery for bowel obstruction that was refractory to medical management. Adequate information was not retrievable for three patients.

Conclusions: A comparison to our previous series reveals similar clinical characteristics and a high rate of node-positive cancer at diagnosis. Our findings also confirm two important clinical indicators of malignancy: recrudescent symptoms after long periods of relative quiescence and small bowel obstruction that is refractory to medical therapy.
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http://dx.doi.org/10.1007/s11605-011-1441-xDOI Listing
May 2011

How important are American Board of Surgery In-Training Examination scores when applying for fellowships?

J Surg Educ 2010 May-Jun;67(3):149-51

Division of General Surgery, Department of Surgery, Mount Sinai Hospital, New York, New York 10029, USA.

Background: The American Board of Surgery In-Training examination (ABSITE) first was administered in 1975 to evaluate a resident's general knowledge as well as the deficiencies within the resident and surgical program. The added importance of this examination in recent years stems from a correlation between ABSITE performance and performance on the American Board of Surgery qualifying examination. However, data are lacking in regard to how fellowship programs view ABSITE scores when considering applicants. Thus, this study was initiated to determine the importance of the ABSITE for surgical residents applying to fellowships.

Study Design: Program coordinators and directors of various surgical fellowships were sent a short survey in regard to the ABSITE. The data then were analyzed.

Results: One hundred forty-eight surveys were completed, with 74.8% of the programs ranking the importance of ABSITE scores as 3 or 4 (on a scale of 1 through 5). Most programs (78.9%) reported no minimum percentile requirement. Those that did required a mean percentile of 54.4. Of the programs, 57.8% placed a greater emphasis on the senior examination versus the junior examination (p = 0.06). When compared with other application factors, the ABSITE score ranked 3rd behind letters of recommendation and a candidate's residency program. Colon and rectal surgery placed the highest importance on ABSITE scores, whereas transplant surgery placed the lowest importance.

Conclusion: The ABSITE score is an important factor for residents applying to surgical fellowship; however, more weight is given to candidates' letters of recommendation and his or her residency program. Applicants should aim to score above the 50th percentile to be competitive for most fellowship programs.
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http://dx.doi.org/10.1016/j.jsurg.2010.02.007DOI Listing
October 2010

Determining and addressing obstacles to the effective use of long-lasting insecticide-impregnated nets in rural Tanzania.

Malar J 2009 Dec 31;8:315. Epub 2009 Dec 31.

Mount Sinai School of Medicine, One Gustave L Levy Place, New York, NY 10029, USA.

Background: The objective of this project was to achieve high, sustainable levels of net coverage in a village in rural Tanzania by combining free distribution of long-lasting insecticide-impregnated nets (LLINs) with community-tailored education. In Tanzania, malaria is the leading cause of morbidity and mortality. Although malaria bed nets have a well-established role in reducing disease burden, few rural households have access to nets, and effective use depends on personal practices and attitudes.

Methods: Five practices and attitudes inconsistent with effective LLIN use were identified from household interviews (n = 10). A randomized survey of villagers (n = 132) verified local prevalence of these practices and attitudes. Community leaders held an educational session for two members of every household addressing these practice and attitudes, demonstrating proper LLIN use, and emphasizing behaviour modification. Attendees received one or two LLINs per household. Surveys distributed three weeks (n = 104) and 15 months (n = 104) post-intervention assessed corrected practices and attitudes. Project efficacy was defined by correction of baseline practices and attitudes as well as high rates of reported daily net use, with statistical significance determined by chi-square test.

Results: Baseline interviews and surveys revealed incorrect practices and attitudes regarding 1) use of nets in dry season, 2) need to retreat LLINs, 3) children napping under nets, 4) need to repair nets, and 5) net procurement as a priority, with 53- 88.6% incorrect responses (11.4-47% correct responses). A three-week follow-up demonstrated 83-95% correct responses. Fifteen-month follow-up showed statistically significant (p < 0.01) corrections from baseline in all five practice and attitudes (39.4-93.3% correct answers). 89.4% of respondents reported using their nets every night, and 93.3% affirmed purchase of nets as a financial priority.

Conclusions: Results suggest that addressing community-specific practices and attitudes prior to LLIN distribution promotes consistent and correct use, and helps change attitudes towards bed nets as a preventative health measure. Future LLIN distributions can learn from the paradigm established in this project.
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http://dx.doi.org/10.1186/1475-2875-8-315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809069PMC
December 2009

Large epiphrenic diverticulum.

J Gastrointest Surg 2010 Jun 4;14(6):1062-4. Epub 2009 Nov 4.

Mount Sinai School of Medicine, New York, NY 10029, USA.

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http://dx.doi.org/10.1007/s11605-009-1075-4DOI Listing
June 2010