Publications by authors named "Michael J Stamos"

182 Publications

Prevention of Autoimmune Diabetes in NOD Mice by Dimethyl Fumarate.

Antioxidants (Basel) 2021 Jan 29;10(2). Epub 2021 Jan 29.

Department of Surgery, University of California, Irvine, CA 92868, USA.

Oxidative stress plays critical roles in the pathogenesis of diabetes. This study tested the hypothesis that by protecting β-cells against oxidative stress and inflammation, an Nrf2 activator, dimethyl fumarate (DMF), may prevent or delay the onset of type 1 diabetes in non-obese diabetic (NOD) mice. Firstly, islet isolation was conducted to confirm the antioxidative effects of DMF oral administration on islet cells. Secondly, in a spontaneous diabetes model, DMF (25 mg/kg) was fed to mice once daily starting at the age of 8 weeks up to the age of 22 weeks. In a cyclophosphamide-induced accelerated diabetes model, DMF (25 mg/kg) was fed to mice twice daily for 2 weeks. In the islet isolation study, DMF administration improved the isolation yield, attenuated oxidative stress and enhanced GCLC and NQO1 expression in the islets. In the spontaneous model, DMF significantly reduced the onset of diabetes compared to the control group (25% vs. 54.2%). In the accelerated model, DMF reduced the onset of diabetes from 58.3% to 16.7%. The insulitis score in the islets of the DMF treatment group (1.6 ± 0.32) was significantly lower than in the control group (3.47 ± 0.21). The serum IL-1α, IL-1β, IL-2, IL-4, IL-5, IL-6, IL-9, IL-12p70, IFN-γ, TNF-α, MCP-1 and CXCL16 levels in the DMF-treated group were lower than in the control group. In conclusion, DMF may protect islet cells and reduce the incidence of autoimmune diabetes in NOD mice by attenuating insulitis and proinflammatory cytokine production.
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http://dx.doi.org/10.3390/antiox10020193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7912218PMC
January 2021

Outcomes of Minimally Invasive Colectomy for Perforated Diverticulitis.

Am Surg 2020 Oct 29:3134820950295. Epub 2020 Oct 29.

Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.

Background: We hypothesized that a laparoscopic approach to sigmoidectomy for perforated diverticulitis is associated with less morbidity and mortality.

Methods: The NSQIP database was used to investigate adult patients who underwent emergent colectomy with end colostomy for perforated diverticulitis. A multivariate analysis using logistic regression was used to compare outcomes of patients by surgical approach.

Results: We found a total of 2937 adult patients who underwent emergent colectomy for perforated diverticulitis during 2012-2017. The rate of minimally invasive surgery (MIS) was 11.4% with 38.6% conversion rate to open. The 30-day mortality and morbidity rates were 8.8% and 65.8%, respectively. Following adjustment using a multivariate analysis, the open approach was associated with higher morbidity (67.2% vs 56.8%, AOR: 1.70, < .01) and mean hospitalization length of patients (13 days vs 10 days, < .01) compared to the MIS approach. Respiratory complications of ventilator dependency (14.3% vs 6%, AOR: 2.95, < .01) and unplanned intubation (7.4% vs 2.4%, AOR: 2.14, = .03) were significantly higher in the open approach. However, patients who underwent the open approach were older (age >70; 33.5% vs 24%, < .01) with more comorbid conditions such as COPD (10.8% vs 7.2%, = .04) and CHF (9% vs 3.1%, < .0).

Conclusion: The MIS approach to emergent partial colectomy for perforated diverticulitis is associated with decreased morbidity and hospitalization length of patients. Utilization of the MIS approach for partial colectomy for perforated diverticulitis is 11.4% with a conversion rate of 38.6%. Efforts should be directed toward increasing the utilization of laparoscopic approaches for the surgical treatment of perforated diverticulitis.
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http://dx.doi.org/10.1177/0003134820950295DOI Listing
October 2020

Short-term outcomes of laparoscopic approach to colonic obstruction for colon cancer.

Surg Endosc 2020 Jun 22. Epub 2020 Jun 22.

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

Background: We speculated that a laparoscopic approach to emergent/urgent partial colectomy for colonic obstruction would be associated with less morbidity and shorter length of stay with similar mortality to open colectomy. We compared the outcomes of laparoscopic and open approaches to emergent/urgent partial colectomy for colonic obstruction from colonic cancer using data from the National Surgical Quality Improvement Program (NSQIP) database for the period of 2012-2017.

Methods: Multivariate analysis compared NSQIP data points following laparoscopic, laparoscopic converted to open, and open colectomy for emergent/urgent colectomy for colonic obstruction from colon cancer from 2012 to 2017.

Results: A total of 1293 patients who underwent emergent colectomy for colon obstruction from colon cancer during 2012-2017 were identified within the NSQIP database. Laparoscopic approach was used for colonic obstruction in 19.3% of operations with a conversion rate of 28.5%. A laparoscopic approach to obstructing colonic cancers was associated with lower morbidity (50% vs. 61.8%, AOR: 0.67, P = 0.01) and shorter hospitalization length (10 days vs. 13 days, mean difference: 3 days, P < 0.01) compared with an open approach. However, the mean operation duration was longer in laparoscopic operations than open operations (159 min vs. 137 min, P < 0.01).

Conclusion: A laparoscopic approach to malignant colonic obstruction is associated with decreased morbidity. This suggests that efforts should be directed towards increasing the utilization of laparoscopic approaches for the surgical treatment of colonic obstruction.
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http://dx.doi.org/10.1007/s00464-020-07743-wDOI Listing
June 2020

Dimethyl Fumarate Alleviates Dextran Sulfate Sodium-Induced Colitis, through the Activation of Nrf2-Mediated Antioxidant and Anti-inflammatory Pathways.

Antioxidants (Basel) 2020 Apr 24;9(4). Epub 2020 Apr 24.

Department of Surgery, University of California, Irvine, CA 92868, USA.

Oxidative stress and chronic inflammation play critical roles in the pathogenesis of ulcerative colitis (UC) and inflammatory bowel diseases (IBD). A previous study has demonstrated that dimethyl fumarate (DMF) protects mice from dextran sulfate sodium (DSS)-induced colitis via its potential antioxidant capacity, and by inhibiting the activation of the NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) inflammasome. This study aims to clarify the nuclear factor erythroid 2-related factor 2/antioxidant responsive element (Nrf2/ARE) pathway pharmacological activation and anti-inflammatory effect by DMF, through focusing on other crucial antioxidant enzymes and inflammatory mediator, including glutamate-cysteine ligase catalytic subunit (GCLC), glutathione peroxidase (GPX) and cyclooxygenase-2 (COX-2), in a DSS-induced colitis mouse model. The oral administration of DMF attenuated the shortening of colons and alleviated colonic inflammation. Furthermore, the expression of key antioxidant enzymes, including GCLC and GPX, in the colonic tissue were significantly increased by DMF administration. In addition, protein expression of the inflammatory mediator, COX-2, was reduced by DMF administration. Our results suggest that DMF alleviates DSS-induced colonic inflammatory damage, likely via up-regulating GCLC and GPX and down-regulating COX-2 protein expression in colonic tissue.
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http://dx.doi.org/10.3390/antiox9040354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222424PMC
April 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

Laparoscopic Sleeve Gastrectomy or Laparoscopic Gastric Bypass for Patients with Metabolic Syndrome: An MBSAQIP Analysis.

Am Surg 2019 Oct;85(10):1108-1112

In patients undergoing bariatric surgery, the presence of metabolic syndrome (MetS) contributes to perioperative morbidity. We aimed to evaluate the utilization and outcome of severely obese patients with MetS who underwent laparoscopic sleeve gastrectomy (LSG) laparoscopic Roux-en-Y gastric bypass (LRYGB). Using the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, data were obtained for patients with MetS undergoing LSG or LRYGB. There were 29,588 MetS patients (LSG: 58.7% LRYGB: 41.3%). There was no significant difference in 30-day mortality (0.1% for LSG 0.2% for LRYGB, adjusted odds ratio (AOR) 0.58, confidence interval (CI) 0.32-1.05, = 0.07) or length of stay between groups (2 ± 2 for LSG 2.2 ± 2 days for LRYGB, = 0.40). Compared with LRYGB, LSG was associated with significantly shorter operative time (78 ± 39 122 ± 54 minutes, < 0.01), lower overall morbidity (2.3% 4.4%, AOR 0.53, CI 0.46-0.60, < 0.01), lower serious morbidity (1.5% 2.3%, AOR 0.64, CI 0.53-0.76, < 0.01), lower 30-day reoperation (1.2% 2.3%, AOR 0.52, CI 0.43-0.63, < 0.01), and lower 30-day readmission (4.2% 6.6%, AOR 0.62, CI 0.55-0.69, < 0.01). In conclusion, LSG is the predominant operation being performed for severely obese patients with MetS, and its popularity may in part be related to its improved perioperative safety profile.
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October 2019

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

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

Patient Co-Morbidity and Functional Status Influence the Occurrence of Hospital Acquired Conditions More Strongly than Hospital Factors.

J Gastrointest Surg 2019 01 17;23(1):163-172. Epub 2018 Sep 17.

Department of Surgery, University of California, San Francisco, CA, USA.

Background: Never events (NE) and hospital-acquired conditions (HAC) are used by Medicare/Medicaid Services to define hospital performance measures that dictate payments/penalties. Pre-op patient comorbidity may significantly influence HAC development.

Methods: We studied 8,118,615 patients from the NIS database (2002-2012) who underwent upper/lower gastrointestinal and/or hepatopancreatobiliary procedures. Multivariate analysis, using logistic regression, was used to identify HAC and NE risk factors.

Results: A total of 63,762 (0.8%) HAC events and 1645 (0.02%) NE were reported. A total of 99.9% of NE were retained foreign body. Most frequent HAC were: pressure ulcer stage III/IV (36.7%), poor glycemic control (26.9%), vascular catheter-associated infection (20.3%), and catheter-associated urinary tract infection (13.7%). Factors correlating with HAC included: open surgical approach (AOR: 1.25, P < 0.01), high-risk patients with significant comorbidity [severe loss function pre-op (AOR: 6.65, P < 0.01), diabetes with complications (AOR: 2.40, P < 0.01), paraplegia (AOR: 3.14, P < 0.01), metastatic cancer (AOR: 1.30, P < 0.01), age > 70 (AOR: 1.09, P < 0.01)], hospital factors [small vs. large (AOR: 1.07, P < 0.01), non-teaching vs teaching (AOR: 1.10, P < 0.01), private profit vs. non-profit/governmental (AOR: 1.20, P < 0.01)], severe preoperative mortality risk (AOR: 3.48, P < 0.01), and non-elective admission (AOR: 1.38, P < 0.01). HAC were associated with increased: hospitalization length (21 vs 7 days, P < 0.01), hospital charges ($164,803 vs $54,858, P < 0.01), and mortality (8 vs 3%, AOR: 1.14, P < 0.01).

Conclusion: HAC incidence was highest among patients with severe comorbid conditions. While small, non-teaching, and for-profit hospitals had increased HAC, the strongest HAC risks were non-modifiable patient factors (preoperative loss function, diabetes, paraplegia, advanced age, etc.). This data questions the validity of using HAC as hospital performance measures, since hospitals caring for these complex patients would be unduly penalized. CMS should consider patient comorbidity as a crucial factor influencing HAC development.
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http://dx.doi.org/10.1007/s11605-018-3957-9DOI Listing
January 2019

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

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

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

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

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

Design: This was a nonrandomized phase II trial.

Settings: The study was conducted at multiple institutions.

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

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

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

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

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

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

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

Robotic versus laparoscopic sleeve gastrectomy: a MBSAQIP analysis.

Surg Endosc 2019 03 20;33(3):917-922. Epub 2018 Aug 20.

Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA.

Background: Laparoscopic sleeve gastrectomy has become the procedure of choice for the treatment of morbid obesity. Robotic sleeve gastrectomy is an alternative surgical option, but its utilization has been low. The aim of this study was to evaluate the contemporary outcomes of robotic sleeve gastrectomy (RSG) versus laparoscopic sleeve gastrectomy (LSG) using a national database from accredited bariatric centers.

Study Design: Using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, clinical data for patients who underwent RSG or LSG were examined. Emergent and revisional cases were excluded. A multivariate logistic regression model was utilized to compare the outcomes between RSG and LSG.

Results: A total of 75,079 patients underwent sleeve gastrectomy with 70,298 (93.6%) LSG and 4781 (6.4%) RSG. Preoperative sleep apnea and hypoalbumenia were significantly higher in the RSG group (P < 0.01). Mean length of stay was similar between RSG and LSG (1.8 ± 2.0 vs. 1.7 ± 2.0 days, P = 0.17). Operative time was longer in the RSG group (102 ± 43 vs. 74 ± 36 min, P < 0.01). There was no significant difference in 30-day mortality between the RSG versus LSG group (0.02% vs. 0.01%, AOR 0.85; 95% CI 0.11-6.46, P = 0.88). However, RSG was associated with higher serious morbidity (1.1% vs. 0.8%, AOR 1.40; 95% CI 1.05-1.86, P < 0.01), higher leak rate (1.5% vs. 0.5%, AOR 3.14; 95% CI 2.65-4.42, P < 0.01), and higher surgical site infection rate (0.7% vs. 0.4%, AOR 1.55; 95% CI 1.08-2.23, P = 0.01).

Conclusions: Robotic sleeve gastrectomy has longer operative time and is associated with higher postoperative morbidity including leak and surgical site infections. Laparoscopy should continue to be the surgical approach of choice for sleeve gastrectomy.
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http://dx.doi.org/10.1007/s00464-018-6387-6DOI Listing
March 2019

High and low estimated glomerular filtration rates are associated with adverse outcomes in patients undergoing surgery for gastrointestinal malignancies.

Nephrol Dial Transplant 2019 05;34(5):810-818

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

Background: Abnormally high estimated glomerular filtration rates (eGFRs) are associated with endothelial dysfunction and frailty. Previous studies have shown that low eGFR is associated with increased morbidity, but few reports address high eGFR. The purpose of this study is to evaluate the association of high eGFR with surgical outcomes in patients undergoing surgery for gastrointestinal malignancies.

Methods: We identified patients who underwent elective surgery for gastrointestinal malignancies from 2005 to 2015 in the American College of Surgeons National Surgical Quality Improvement Program database. We evaluated associations of eGFR with surgical outcomes by Cox or logistic models with restricted cubic spline functions, adjusting for case mix variables (i.e. age, gender, race and diabetes).

Results: The median eGFR is 83 (interquartile range 67-96) mL/min/1.73 m2. Thirty-day mortality was 1.9% (2555/136 896). There is a U-shaped relationship between eGFR and 30-day mortality. The adjusted hazard ratios (95% confidence intervals) for eGFRs of 30, 60, 105 and 120 mL/min/1.73 m2 (versus 90 mL/min/1.73 m2) are 1.73 (1.52-1.97), 1.00 (0.89-1.11), 1.42 (1.31-1.55) and 2.20 (1.79-2.70), respectively. Similar associations are shown for other surgical outcomes, including return to the operating room and postoperative pneumonia. Subgroup analyses show that eGFRs both higher and lower than the respective medians are consistently associated with a higher risk of adverse outcomes across age, gender and race.

Conclusions: High and low eGFRs are associated with more adverse surgical outcomes in patients undergoing surgery for gastrointestinal malignancies. The eGFR associated with the lowest postoperative risk is approximately at the median eGFR of a given population.
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http://dx.doi.org/10.1093/ndt/gfy108DOI Listing
May 2019

Risk Factors for Gastrointestinal Leak after Bariatric Surgery: MBASQIP Analysis.

J Am Coll Surg 2018 07 30;227(1):135-141. Epub 2018 Mar 30.

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

Background: Gastrointestinal leak remains one of the most dreaded complications in bariatric surgery. We aimed to evaluate risk factors and the impact of common perioperative interventions on the development of leak in patients who underwent laparoscopic bariatric surgery.

Study Design: Using the 2015 database of accredited centers, data were analyzed for patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass (LRYGB). Emergent, revisional, and converted cases were excluded. Multivariate logistic regression was used to analyze risk factors for leak, including provocative testing of anastomosis, surgical drain placement, and use of postoperative swallow study.

Results: Data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (n = 92,495 [69.3%]) and LRYGB (n = 40,983 [30.7%]) were analyzed. Overall leak rate was 0.7% (938 of 133,478). Factors associated with increased risk for leak were oxygen dependency (adjusted odds ratio [AOR] 1.97), hypoalbuminemia (AOR 1.66), sleep apnea (AOR 1.52), hypertension (AOR 1.36), and diabetes (AOR 1.18). Compared with LRYGB, laparoscopic sleeve gastrectomy was associated with a lower risk of leak (AOR 0.52; 95% CI 0.44 to 0.61; p < 0.01). Intraoperative provocative test was performed in 81.9% of cases and the leak rate was higher in patients with vs without a provocative test (0.8% vs 0.4%, respectively; p < 0.01). A surgical drain was placed in 24.5% of cases and the leak rate was higher in patients with vs without a surgical drain placed (1.6% vs 0.4%, respectively; p < 0.01). A swallow study was performed in 41% of cases and the leak rate was similar between patients with vs without swallow study (0.7% vs 0.7%; p = 0.50).

Conclusions: The overall rate of gastrointestinal leak in bariatric surgery is low. Certain preoperative factors, procedural type (LRYGB), and interventions (intraoperative provocative test and surgical drain placement) were associated with a higher risk for leaks.
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http://dx.doi.org/10.1016/j.jamcollsurg.2018.03.030DOI Listing
July 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

Discussion of: "Venous thromboembolism in common laparoscopic abdominal surgical operations".

Am J Surg 2017 12 5;214(6):1133-1134. Epub 2017 Oct 5.

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

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http://dx.doi.org/10.1016/j.amjsurg.2017.10.009DOI Listing
December 2017

Massive Submucosal Ganglia in Colonic Inertia.

Arch Pathol Lab Med 2018 Feb 5;142(2):208-212. Epub 2017 Oct 5.

Context: - Colonic inertia is a debilitating form of primary chronic constipation with unknown etiology and diagnostic criteria, often requiring pancolectomy. We have occasionally observed massively enlarged submucosal ganglia containing at least 20 perikarya, in addition to previously described giant ganglia with greater than 8 perikarya, in cases of colonic inertia. These massively enlarged ganglia have yet to be formally recognized.

Objective: - To determine whether such "massive submucosal ganglia," defined as ganglia harboring at least 20 perikarya, characterize colonic inertia.

Design: - We retrospectively reviewed specimens from colectomies of patients with colonic inertia and compared the prevalence of massive submucosal ganglia occurring in this setting to the prevalence of massive submucosal ganglia occurring in a set of control specimens from patients lacking chronic constipation.

Results: - Seven of 8 specimens affected by colonic inertia harbored 1 to 4 massive ganglia, for a total of 11 massive ganglia. One specimen lacked massive ganglia but had limited sampling and nearly massive ganglia. Massive ganglia occupied both superficial and deep submucosal plexus. The patient with 4 massive ganglia also had 1 mitotically active giant ganglion. Only 1 massive ganglion occupied the entire set of 10 specimens from patients lacking chronic constipation.

Conclusions: - We performed the first, albeit distinctly small, study of massive submucosal ganglia and showed that massive ganglia may be linked to colonic inertia. Further, larger studies are necessary to determine whether massive ganglia are pathogenetic or secondary phenomena, and whether massive ganglia or mitotically active ganglia distinguish colonic inertia from other types of chronic constipation.
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http://dx.doi.org/10.5858/arpa.2016-0551-OADOI Listing
February 2018

Venous thromboembolism in common laparoscopic abdominal surgical operations.

Am J Surg 2017 Dec 18;214(6):1127-1132. Epub 2017 Sep 18.

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

Background: Venous thromboembolism (VTE) is potentially a serious postoperative complication. We examined the incidence and outcome of VTE among different laparoscopic abdominal surgical operations for benign diseases.

Methods: The National Surgical Quality Improvement Program database was utilized to evaluate all patients with benign disease who underwent laparoscopic abdominal operations including colorectal surgery, bariatric surgery, cholecystectomy, esophageal surgery, abdominal wall hernia repair, and appendectomy from 2005 to 2014. Multivariate logistic regression analysis was performed.

Results: 750,159 patients were studied and the overall incidence of VTE was 0.32% within 30 days of operation. Colorectal surgery had the highest incidence of VTE (734/65512, 1.12%) with significantly longest length of stay and operative time. Patients who developed VTE had higher mortality and worse outcomes compared to non-VTE patients.

Conclusions: Laparoscopic colorectal operations for benign disease is at higher risk for development of VTE compared to other laparoscopic abdominal operations. Further studies should be performed to elucidate the underlying mechanisms for our finding.
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http://dx.doi.org/10.1016/j.amjsurg.2017.08.032DOI Listing
December 2017

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

Association of pre-operative estimated GFR on post-operative pulmonary complications in laparoscopic surgeries.

Sci Rep 2017 07 26;7(1):6504. Epub 2017 Jul 26.

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

Despite a large body of evidence showing the pandemic of chronic kidney disease, the impact of pre-operative kidney function on the risk of post-operative pulmonary complications (PPCs) is not well known. We used multivariable logistic regression analyses with 3-level hierarchical adjustments to identify the association of pre-operative estimated glomerular filtration rate (eGFR) with PPCs in laparoscopic surgeries. Among 452,213 patients between 2005 and 2013 in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Database, a total of 3,727 patients (0.9%) experienced PPCs. We found a gradient association between lower eGFR and higher likelihood of PPCs in the unadjusted model. In the case-mix adjusted model, a reverse-J-shaped association was observed; a small albeit significant association with the highest eGFR category emerged. Further adjustment slightly attenuated these associations, but the PPCs risk in the eGFR groups of <30, 30-60, and ≥120 mL/min/1.73 m remained significant: odds ratios (95% confidence intervals) of 1.82 (1.54-2.16), 1.38 (1.24-1.54), and 1.28 (1.07-1.53), respectively (reference: 90-120 mL/min/1.73 m). Our findings propose a need for careful pre-operative evaluation of cardiovascular and pulmonary functions and post-operative fluid management among patients with not only lower but also very high eGFR.
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http://dx.doi.org/10.1038/s41598-017-06842-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5529443PMC
July 2017

Treatment with dimethyl fumarate ameliorates liver ischemia/reperfusion injury.

World J Gastroenterol 2017 Jul;23(25):4508-4516

Chie Takasu, Nosratola D Vaziri, Shiri Li, Lourdes Robles, Kelly Vo, Mizuki Takasu, Christine Pham, Seyed H Farzaneh, Michael J Stamos, Hirohito Ichii, Department of Surgery, Medicine, University of California, Irvine, CA 92868, United States.

Aim: To investigate the hypothesis that treatment with dimethyl fumarate (DMF) may ameliorate liver ischemia/reperfusion injury (I/RI).

Methods: Rats were divided into 3 groups: sham, control (CTL), and DMF. DMF (25 mg/kg, twice/d) was orally administered for 2 d before the procedure. The CTL and DMF rats were subjected to ischemia for 1 h and reperfusion for 2 h. The serum alanine aminotransferase (ALT) and malondialdehyde (MDA) levels, adenosine triphosphate (ATP), NO × metabolites, anti-oxidant enzyme expression level, anti-inflammatory effect, and anti-apoptotic effect were determined.

Results: Histological tissue damage was significantly reduced in the DMF group (Suzuki scores: sham: 0 ± 0; CTL: 9.3 ± 0.5; DMF: 2.5 ± 1.2; sham CTL, < 0.0001; CTL DMF, < 0.0001). This effect was associated with significantly lower serum ALT (DMF 5026 ± 2305 U/L CTL 10592 ± 1152 U/L, = 0.04) and MDA (DMF 18.2 ± 1.4 μmol/L CTL 26.0 ± 1.0 μmol/L, = 0.0009). DMF effectively improved the ATP content (DMF 20.3 ± 0.4 nmol/mg CTL 18.3 ± 0.6 nmol/mg, = 0.02), myeloperoxidase activity (DMF 7.8 ± 0.4 mU/mL CTL 6.0 ± 0.5 mU/mL, = 0.01) and level of endothelial nitric oxide synthase expression (DMF 0.38 ± 0.05-fold 0.17 ± 0.06-fold, = 0.02). The higher expression levels of anti-oxidant enzymes (catalase and glutamate-cysteine ligase modifier subunit and lower levels of key inflammatory mediators (nuclear factor-kappa B and cyclooxygenase-2 were confirmed in the DMF group.

Conclusion: DMF improved the liver function and the anti-oxidant and inflammation status following I/RI. Treatment with DMF could be a promising strategy in patients with liver I/RI.
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http://dx.doi.org/10.3748/wjg.v23.i25.4508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5504366PMC
July 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

Risk of Postoperative Venous Thromboembolism Among Pregnant Women.

Am J Cardiol 2017 Aug 11;120(3):479-483. Epub 2017 May 11.

Department of Surgery, University of California Irvine, Orange, California. Electronic address:

Venous thromboembolism (VTE) is a critical complication after surgery. Although pregnancy is a known risk factor of VTE, available data on the risk of postoperative VTE are scarce. Using the American College of Surgeons National Surgical Quality Improvement Program database between 2006 and 2012, we matched 2,582 pregnant women to 103,640 nonpregnant women based on age, race, body mass index, and modified Rogers score. Pregnant women, compared with matched nonpregnant women, experienced higher incidence of VTE (0.5% vs 0.3%; odds ratio 1.93, 95% confidence interval 1.1 to 3.37, p = 0.02). Pregnant women also showed higher risk of pneumonia, ventilator dependence ≥48 hours, bleeding, and sepsis than did the counterparts. In conclusion, pregnancy was associated with higher risk of VTE after surgery as well as other postoperative complications. The absolute risk difference was small, and careful evaluation against the potential risk and benefit should be given when surgical treatment is considered among pregnant women.
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http://dx.doi.org/10.1016/j.amjcard.2017.04.053DOI Listing
August 2017

The Role of Fluorescent Angiography in Anastomotic Leaks.

Surg Technol Int 2017 Jul;30:83-88

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

Anastomotic leaks following colorectal anastomosis has substantial implications including increased morbidity, longer hospitalization, and reduced overall survival. The etiology of leaks includes patient factors, technical factors, and anastomotic perfusion. An intact anastomotic blood supply is especially crucial in the physiology of anastomotic healing. To date, no established intraoperative methods have been developed that reliably and reproducibly identify and prevent leak occurrence. Recently, fluorescent angiography (FA) with indocyanine green (ICG) has emerged as an innovative modality for intraoperative perfusion assessment. ICG-FA can be performed before or after intestinal resection or, alternatively, after creation of the anastomosis. Angiographic assessment with near-infrared camera filters allows determination of perfusion adequacy, guiding additional intestinal resection and anastomotic revision. Early clinical experiences with ICG-FA demonstrated safety and feasibility. Large, multi-center prospective trials, such as the Perfusion Assessment in Laparoscopic Left-Sided/Anterior Resection Study (PILLAR II), demonstrated ease of use with remarkably low anastomotic leak rates after ICG-FA-guided intraoperative revision. Current randomized control trials featuring utilization in ICG-FA in low anterior resection are currently underway and will further clarify the role of ICG-FA in leak identification and prevention. Apart from colorectal surgery, FA has also been successfully employed in other surgical disciplines such as plastic surgery, vascular surgery, foregut surgery, urology, and gynecology.
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July 2017

A Nationwide Analysis of Kidney Autotransplantation.

Am Surg 2017 Feb;83(2):162-169

There are limited data regarding outcomes of patients underwent kidney autotransplantation. This study aims to investigate outcomes of such patients. The nationwide inpatient sample database was used to identify patients underwent kidney autotransplantation during 2002 to 2012. Multivariate analyses using logistic regression were performed to investigate morbidity predictors. A total of 817 patients underwent kidney autotransplantation from 2002 to 2012. The most common indication of surgery was renal artery pathology (22.7%) followed by ureter pathology (17%). Overall, 97.7 per cent of operations were performed in urban teaching hospitals. The number of procedures from 2008 to 2012 were significantly higher compared with the number of them from 2002 to 2007 (473 vs 345, P < 0.01). The overall mortality and morbidity of patients were 1.3 and 46.2 per cent, respectively. The most common postoperative complications were transplanted kidney failure (10.7%) followed by hemorrhagic complications (9.7%). Obesity [adjusted odds ratio (AOR): 9.62, P < 0.01], fluid and electrolyte disorders (AOR: 3.67, P < 0.01), and preoperative chronic kidney disease (AOR: 1.80, P = 0.03) were predictors of morbidity in patients. In conclusion, Kidney autotransplantation is associated with low mortality but a high morbidity rate. The most common indications of kidney autotransplantation are renal artery and ureter pathologies, respectively. A kidney transplant failure rate of 10.7 per cent was observed in patients with kidney autotransplantation. The most common postoperative complication was hemorrhagic in nature.
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February 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

Bariatric surgery attenuates colitis in an obese murine model.

Surg Obes Relat Dis 2017 Apr 20;13(4):661-668. Epub 2016 Dec 20.

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

Background: Obesity and inflammatory bowel disease (IBD) represent chronic inflammatory conditions. Bariatric surgery improves some obesity-related co-morbidities, but the effects of bariatric surgery on IBD have not been well studied.

Objectives: To examine if bariatric surgery may attenuate colitis in an obese murine model of IBD and study the mechanisms underlying the postsurgical amelioration of intestinal inflammation.

Setting: University of California Irvine, Department of Surgery and Microbiology laboratories.

Methods: Obese mice were assigned to one of 2 bariatric procedures [Duodenojejunal Bypass (DJB n = 6), Sleeve Gastrectomy (SG n = 8)]. Sham-operated mice were (Sham n = 8) were used as a control. After recovering from surgery, IBD was induced by administration of 2% dextran sodium sulfate. Fecal samples were collected before and after IBD induction for microbiome analysis. Pathologic analyses and immunohistochemical staining were performed on colon.

Results: Survival after DJB and SG was higher relative to Sham mice. Histologically, DJB mice had significantly less intestinal inflammation. The observed improvements were not related to a difference in weight among the groups. Farnesoid X receptor staining in the colon was observed quantitatively more in DJB than in SG and sham mice. A statistically significant increase in the number of Lactobacillales was observed in the stool of mice after DJB.

Conclusion: These results suggest that bariatric surgery, in particular DJB, reduces the severity of colitis in a chemically-induced IBD murine model. The anticolitis effects of DJB may be associated with Farnesoid X receptor regulation and gut microbiome rearrangements.
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http://dx.doi.org/10.1016/j.soard.2016.10.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847609PMC
April 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