Publications by authors named "Tara M Connelly"

47 Publications

Lymph node recurrence after right colon resection for cancer: evidence for the utilisation of complete mesocolic excision.

BMJ Case Rep 2022 May 12;15(5). Epub 2022 May 12.

Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA.

Complete mesocolic excision (CME) of colon cancer is a resection performed along embryological planes to include the completely intact mesentery surrounding the tumour with a high central vascular ligation. The aim is to remove all lymph nodes draining the cancer. Proponents of the technique cite the significantly decreased local recurrence and improved 5-year survival rates associated with CME versus conventional colectomy. Although increasingly performed in many centres, it has not yet gained widespread acceptance as it is technically more challenging and can incur an increased bleeding risk. A man in his 80s underwent a conventional right hemicolectomy for a pT4aN2aM0 ascending colon cancer at another institution. This was followed by chemotherapy. He presented to our institution 2 years later with an isolated 3.7×3.2 cm mesenteric tumour adjacent to his anastomosis. There was no intraluminal recurrence. He then underwent a repeat extended right colectomy with CME. Pathology confirmed lymph node recurrence. His case demonstrates the importance of CME in reducing carcinoma recurrence risk.
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http://dx.doi.org/10.1136/bcr-2021-247904DOI Listing
May 2022

Primary cutaneous phalangeal neuroendocrine/squamous cell carcinoma with mixed axillary metastasis.

BMJ Case Rep 2022 Mar 29;15(3). Epub 2022 Mar 29.

General Surgery, Tallaght University Hospital, Dublin, Ireland.

Cutaneous neuroendocrine tumours are rare and aggressive tumours associated with advanced age and immunosuppression. They are typically characterised by a high rate of local recurrence and nodal disease. The presence of a mixed squamous cell component is rare. These tumours are uncommonly found on the hand. We present a case and histological images of a 78-year-old woman with a primary CK20 negative TTF-1 positive cutaneous neuroendocrine tumour with squamous dedifferentiation arising from the fifth digit with axillary metastasis showing a mixed phenotype. Initial biopsy of the lesion was positive for chromogranin, synaptophysin and TTF-1, but negative for CK20, Melan-A and S100. After CT of the thorax abdomen and pelvis and octreotide single positron emission CT demonstrated a 15 mm axillary metastasis and no evidence of distal disease, our patient underwent an amputation of the affected digit and an axillary lymph node dissection. She is currently awaiting adjuvant chemoradiotherapy. Only two cases are reported in the literature to have mixed squamous/neuroendocrine features. We present the first case which is CK20 negative and TTF-1 positive.
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http://dx.doi.org/10.1136/bcr-2020-240919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8966523PMC
March 2022

Right colon, left colon, and rectal cancer have different oncologic and quality of life outcomes.

Int J Colorectal Dis 2022 Apr 21;37(4):939-948. Epub 2022 Mar 21.

Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, A3044122, USA.

Purpose: Colorectal cancer patients are commonly considered a single entity in outcomes studies. This is particularly true for quality of life (QOL) studies. This study aims to compare oncologic and QOL outcomes between right colon, left colon, and rectal cancer in patients operated on in a single high-volume institution.

Methods: A prospectively maintained database was queried to identify patients with pathological stages I-III colorectal adenocarcinoma electively operated on with curative intent between 2000 and 2010. Patient characteristics, perioperative and oncologic outcomes, and QOL were compared according to cancer location.

Results: Two-thousand sixty-five (606 right colon cancer [RCC], 366 left colon cancer [LCC], and 1093 rectal cancer [RC]) patients met the inclusion criteria. LCC had better overall survival (OS) and disease-free survival (DFS) in the non-adjusted analysis (p < 0.001) and better OS in multivariate analysis adjusted by age, gender, ASA, chemotherapy, and pathological stage (p = 0.024). Although RCC had worse OS and DFS in non-adjusted survival analysis than LCC and RC, when adjusted for the factors above, RCC had better survival outcomes than RC, but not LCC. COX regression analysis showed age (p < 0.001), gender (p = 0.016), ASA (p < 0.001), pathological stage (p < 0.001), adjuvant chemotherapy (p = 0.043), and cancer location (p = 0.024) were independently associated with OS. Age (p < 0.001), gender (p = 0.030), ASA (p = 0.004), and pathological stage (p < 0.001) were independently associated with DFS. Patients with RC reported more sexual dysfunction and work restrictions than colon cancers (p = 0.015 and p < 0.001, respectively).

Conclusion: In an adjusted multivariate analysis, colon cancers demonstrated better survival outcomes when compared to rectal cancers.
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http://dx.doi.org/10.1007/s00384-022-04121-xDOI Listing
April 2022

A Low rectal GIST.

BMJ Case Rep 2022 Mar 14;15(3). Epub 2022 Mar 14.

Colorectal Surgery, Cleveland Clinic Main Campus Hospital, Cleveland, Ohio, USA.

A man in his 70s presented with narrowing of his stool calibre and a palpable mass on rectal examination. Colonoscopy revealed a submucosal bulge without a mucosal lesion. CT and MRI demonstrated an 8×5.4×7 cm mass in lower rectum. Biopsy of the mass confirmed a rectal gastrointestinal stromal tumour (GIST). It was moderately sensitive to neoadjuvant imatinib and radiotherapy, which slightly downsized the tumour. He required abdominal perineal resection with curative intent. Uncommonly found in the rectum, when located here, GISTs are typically aggressive and are a rare cause of stool calibre narrowing. Rectal GISTs should be considered in patients presenting with this symptom.
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http://dx.doi.org/10.1136/bcr-2021-248505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8921934PMC
March 2022

Outcomes of the Macroscopically Normal Appendix Left in Situ in Patients with Suspected Appendicitis.

World J Surg 2022 Jun 10;46(6):1353-1358. Epub 2022 Mar 10.

Department of Academic Surgery, University Hospital Waterford, University College Cork, Dunmore Road, Waterford, Ireland.

Background: Right iliac fossa (RIF) pain is a common indication for laparoscopy to diagnose and treat appendicitis. When a macroscopically normal appendix is found, there is no standard consensus regarding excision. Some surgeons remove the appendix due to the risk of microscopic inflammation and to avoid a future, repeat laparoscopy for possible appendicitis. Alternatively, others leave the appendix in situ to avoid morbidity from a potentially unnecessary procedure. We aimed to evaluate the outcomes of patients with macroscopically normal appendices left in situ.

Methods: All emergency laparoscopies without appendicectomy between January 1st 2010- December 31st 2020 were identified from theatre records. All operative notes were individually evaluated and comments on the macroscopic appearance of the appendix and any intra-operative pathology were recorded. Only patients undergoing laparoscopy for suspected appendicitis with macroscopically normal appendices were included.

Results: A total of 120 patients [median age 21.68 (range 9-90.8) years] were included. The cohort was predominantly female (n=105, 87.5%). Forty-eight patients (40.0%) had a positive finding during index laparoscopy. During a median duration of 94.5 (range 8-131) months' follow-up, 16 patients (13.33%) underwent a repeat laparoscopy for recurrent RIF pain. Thirteen (10.8% of total cohort) subsequently underwent an appendicectomy. Histology confirmed acute appendicitis in six cases (4.17% of entire cohort). On subanalysis of smaller cohort, index laparoscopies with no positive findings (n=72), nine patients (12.5%) underwent appendicectomy with two (2.7%) appendices demonstrating appendicitis on histological examination.

Conclusion: 87% of the total cohort with a normal appendix at laparoscopy for RIF pain did not undergo further laparoscopy. Less than 5% of the total cohort and 2.7% of subanalysis cohort had an appendicectomy for histologically-proven appendicitis within the follow-up period. From the evidence in this study, we conclude that leaving the appendix in situ unless macroscopically inflamed is a viable alternative to excision.
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http://dx.doi.org/10.1007/s00268-022-06497-xDOI Listing
June 2022

Quality of life meta-analysis following coloanal anastomosis versus abdominoperineal resection for low rectal cancer.

Colorectal Dis 2022 Feb 23. Epub 2022 Feb 23.

Department of Colorectal Surgery, Saint James's Hospital, Dublin, Ireland.

Aim: In low rectal cancers without sphincter involvement a permanent stoma can be avoided without compromising oncological safety. Functional outcomes following coloanal anastomosis (CAA) compared to abdominoperineal excision (APR) may be significantly different. This study examines all available comparative quality of life (QoL) data for patients undergoing CAA versus APR for low rectal cancer.

Methods: Published studies with comparative data on QoL outcomes following CAA versus APR for low rectal cancer were extracted from electronic databases. The study was registered with PROSPERO and adhered to PRISMA (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Data was combined using random-effects models.

Results: Seven comparative series examined QoL in 527 patients. There was no difference in the numbers receiving neoadjuvant radiotherapy in the APR and CAA groups (OR: 1.19, 95% CI: 0.78-1.81, p = 0.43). CAA was associated with higher mean scores for physical functioning(std mean diff -7.08, 95% CI: -11.92 to -2.25, p = 0.004) and body image (std. mean diff 11.11, 95% CI: 6.04-16.18, p < 0.0001). Male sexual problems were significantly increased in patients who had undergone APR compared to CAA (std. mean diff -16.20, 95% CI: -25.76 to -6.64, p = 0.0009). Patients who had an APR reported more fatigue, dyspnoea and appetite loss. Those who had a CAA reported higher scores for both constipation and diarrhoea.

Discussion: It is reasonable to offer a CAA to motivated patients where oncological outcomes will not be threatened. QoL outcomes appear to be superior when intestinal continuity is maintained, and permanent stoma avoided.
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http://dx.doi.org/10.1111/codi.16099DOI Listing
February 2022

An analysis of the cost and impact of cosmetic tourism and its associated complications: A multi institutional study.

Surgeon 2022 Jan 7. Epub 2022 Jan 7.

Department of Breast and General Surgery, University Hospital Waterford, Waterford, Ireland. Electronic address:

Background And Purpose: The increasing cost of cosmetic procedures, long elective waiting times in the public system and affordability of procedures offered abroad has driven the rapid growth of cosmetic tourism. The incidence and cost of patients presenting to the Irish health service with complications related to cosmetic procedures carried out in overseas institutions is largely unknown. This heterogenous group of patients is challenging to identify. Limited data exists for this patient group in the Irish context. We aimed to perform a multicentre audit and cost analysis of patients presenting to Irish health services with complications related to cosmetic procedures performed in overseas institutions over a 2 year period.

Methods: Patients presenting to two University Hospitals from March 2019-April 2021 with complications after a cosmetic surgical procedure was performed abroad were studied. The HPO ABF 2020 price list data was used to calculate the inpatient and procedure cost for each subject.

Main Findings: 14 (13/92.8% female, mean age 43 ± 11.85 years) patients presented during the study period. Countries of cosmetic operation included: Belgium (6/46.2%), the UK (2/15.4%), Latvia, Turkey, Poland, Lithuania, and Estonia (1 patient/7.7% each country). All required a re-operative procedure. These interventions included: removal of infected implant (n = 1), adjustment or removal of a gastric band (n = 9) and debridement of an infected/necrotic wound (n = 3). Mean length of stay was 9.14 ± 7.48 (range 2-28) days. Five (38.4%) patients required vac dressing. The mean cost of the cohort for the interventional procedure and in-patient stay was €15912.53 (+/- €6388). The sum total of all the costs for the cohort was €231038.60.

Conclusions: Significant costs were associated with prolonged hospital admissions, operative interventions, intravenous antibiotics, VAC dressing application and follow up visits. Complications from procedures performed in overseas institutions account for a significant cost burden to health services in Ireland.
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http://dx.doi.org/10.1016/j.surge.2021.12.007DOI Listing
January 2022

Gallstone ileus in an elderly orthopaedic patient managed with enterolithotomy: a video vignette.

Colorectal Dis 2021 11 9;23(11):3030. Epub 2021 Sep 9.

Department of Academic Surgery, University Hospital Waterford, Waterford, Ireland.

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http://dx.doi.org/10.1111/codi.15888DOI Listing
November 2021

Sleepy Surgeons: A Multi-Method Assessment of Sleep Deprivation and Performance in Surgery.

J Surg Res 2021 12 23;268:145-157. Epub 2021 Jul 23.

Department of Surgery, School of Medicine, Trinity College Dublin, Department of Neurophysiology, Department of Surgery, Tallaght University Hospital, Dublin, Ireland.

Background: Minimum rest is mandated in high stake industries such as aviation. The current system of healthcare provision permits on-call surgeons to work in sleep deprived states when performing procedures. Fatigue has been demonstrated to negatively affect performance. This study aimed to explore measurements of sleep deprivation and their impact on simulated performance.

Methods: This was a single site study conducted between September 2019 and February 2020. Surgical trainee and consultants were conveniently sampled from a single site. All testing was done between 7 AM and 9 AM. Participants completed electroencephalogram testing using a modified Multiple Sleep Latency Test testing for objective sleep measurement, the Pittsburgh Sleep Quality Index, Chalder Fatigue Scale and Epworth Sleepiness Scale for subjective sleep measurement. The Psychomotor Vigilance Task and the SIMENDO simulated tasks were used for standardized performance assessment.

Results: Surgeons entered sleep in 6 min, on average pre-call. This significantly decreased to an average of 164 s post-call (P = 0.016). Pittsburgh Sleep Quality Index scoring was 5, indicating poor baseline sleep quality. There was higher self-reported fatigue and sleepiness in post-call states. Performance decrements were noted in cognitive performance reaction time and aspects of technical instrument proficiency.

Conclusions: Surgeons are objectively sleep deprived pre-call according to internationally recognized guidelines. This sleep deprivation increases significantly in post-call states. Tasks with higher cognitive demands showed greater levels of diminished performance compared to those with lower cognitive demands. Current models of provision of surgical on-call are not conducive to optimizing sleep in surgeons. Prioritization of workload in post-call states, focusing on preserving individuals cognitive resources and utilizing lower cognitively demanding aspects of work is likely to have positive impacts on performance outcomes.
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http://dx.doi.org/10.1016/j.jss.2021.06.047DOI Listing
December 2021

Self-reported surgeon health behaviours: A multicentre, cross-sectional exploration into the modifiable factors that impact surgical performance with the association of surgeons in training.

Ann Med Surg (Lond) 2021 May 27;65:102299. Epub 2021 Apr 27.

Department of Surgery, School of Medicine, Trinity College Dublin, The University of Dublin, Ireland.

Introduction: Surgeons regularly educate patients on health promoting behaviours including diet, sleep and exercise. No study thus far has explored surgeons' personal compliance with these health behaviours and their relationship with surgical performance. The primary outcomes of this study were self-reported health, health related behaviours, wellbeing, fatigue and surgical performance.

Methods: A survey of validated themes on health related behaviours, workplace variables and performance was distributed to surgical trainees and consultants in the UK and Ireland through the Association for Surgeons in Training (ASiT). Non-parametric analysis was used to determine inferential associations.

Results: Ninety five surgeons (51.5% female, 39.9% registrars) completed the survey. 94% and 74% reported 'good' or better overall health and mental wellbeing respectively. The majority (54.7%) reported inconsistent sleep patterns. Less than a quarter engage in regular exercise. Sixty two and 64.2% reported being regularly fatigued and bothered by feelings of anxiety and/or depression respectively. Poor self-reported health and wellbeing were associated with poorer reported off-call performance (p < .01). Higher levels of fatigue negatively impacted self-reported surgical and non-surgical task proficiency (p < .01).

Discussion And Conclusion: Surgeons reported high levels of overall health. However, healthy behaviours around sleep, diet and exercise were not consistently reported. Fewer reported good mental health and emotional well-being. Self-reported health behaviours including sleep and physical activity were associated with surgical performance. Strategies to improve modifiable lifestyle factors which will optimise physical health, mental wellbeing and levels of fatigue may optimise surgical performance.
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http://dx.doi.org/10.1016/j.amsu.2021.102299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8111267PMC
May 2021

COVID-19 and surgery: A thematic analysis of unintended consequences on performance, practice and surgical training.

Surgeon 2021 Feb 3;19(1):e20-e27. Epub 2020 Aug 3.

Discipline of Surgery, School of Medicine, Trinity College Dublin, The University of Dublin; Department of Surgery, Tallaght University Hospital, Ireland.

Purpose: The shift in the national focus and allocation of resources to the management of COVID19 has led to significant changes to surgical practice including the delay of elective surgery. The aim of this study was to explore the implications of such changes on surgeons.

Method: Using a qualitative study design, semi-structured interviews were conducted with general surgery consultants and non-consultant hospital doctors from a major tertiary hospital in the Dublin region between March-May 2020. Data collection proceeded iteratively using a thematic analysis approach with quality controls such as memoing and collaborative analysis.

Results: Fourteen surgeons (8 male, 6 female) were interviewed. The majority (n = 11, 78.6%) were NCHDs. Significant themes determined included 'impacts' on a variety of constructs such as performance, self-reported fatigue and wellbeing. Training themes elucidated included the effects of the cancellation of elective admissions on reduced operative exposure for trainees. Senior surgical staff were particularly focused on increased complexity in patient management. New policy requirements such as personal protective equipment use and novel rotas have had implications for aspects of work engagement. The pandemic and subsequent national restrictions imposed has afforded opportunities for improved well-being but also resulted in greater solitude in surgeons.

Conclusions: Rhetoric surrounding fatigue management and virus control dominates the conversation on the relationship between COVID-19 and surgery. Tipping the balance back to parity of fatigue management with service delivery in surgery will be key for sustainability of the surgical workforce.
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http://dx.doi.org/10.1016/j.surge.2020.07.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7396881PMC
February 2021

Do get suspicious: diagnosing appendicular goblet cell carcinoid.

ANZ J Surg 2019 11;89(11):1524

Department of Surgery, University Hospital Waterford, Waterford, Ireland.

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http://dx.doi.org/10.1111/ans.15437DOI Listing
November 2019

The 100 most influential manuscripts in robotic surgery: a bibliometric analysis.

J Robot Surg 2020 Feb 4;14(1):155-165. Epub 2019 Apr 4.

Department of Colorectal Surgery, University Hospital Limerick, Dooradoyle, Limerick, Ireland.

Since the first robotic assisted surgery in 1985, the number of procedures performed annually has steadily increased. Bibliometric analysis highlights the key studies that have influenced current practice in a field of interest. We use bibliometric analysis to evaluate the 100 most cited manuscripts on robotic surgery and discuss their content and influence on the evolution of the platform. The terms 'robotic surgery,' 'robot assisted surgery' and 'robot-assisted surgery' were used to search Thomson Reuters Web of Science database for full length, English language manuscripts. The top 100 cited manuscripts were analyzed by manuscript type, surgical specialty, first and last author, institution, year and journal of publication. 14,980 manuscripts were returned. Within the top 100 cited manuscripts, the majority featured urological surgery (n = 28), followed by combined results from multiple surgical subspecialties (n = 15) and colorectal surgery (n = 13). The majority of manuscripts featured case series/reports (n = 42), followed by comparative studies (n = 24). The most cited paper authored by Nelson et al. (432 citations) reviewed technological advances in the field. The year and country with the greatest number of publications were 2009 (n = 15) and the USA (n = 68). The Johns Hopkins University published the most top 100 manuscripts (n = 18). The 100 most cited manuscripts reflect the progression of robotic surgery from a basic instrument-holding platform to today's articulated instruments with 3D technology. From feasibility studies to multicenter trials, this analysis demonstrates how robotic assisted surgery has gained acceptance in urological, colorectal, general, cardiothoracic, orthopedic, maxillofacial and neuro surgery.
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http://dx.doi.org/10.1007/s11701-019-00956-9DOI Listing
February 2020

An assessment of the quality and content of information on diverticulitis on the internet.

Surgeon 2018 Dec 22;16(6):359-364. Epub 2018 May 22.

Department of Surgery, University Hospital Waterford, Waterford, Ireland. Electronic address:

Aim: Although commonly the first port of call for medical information, the internet provides unregulated information of variable quality. We aimed to evaluate commonly accessed web-based patient information on diverticulitis using validated and novel scoring systems.

Methods: The top internet search engines (Google/Bing/Yahoo) were queried using the keyword 'diverticulitis.' The first 20 websites from each were graded using the DISCERN and Journal of the American Medical Association (JAMA) benchmark criteria. A novel diverticulitis-specific score was devised and applied.

Results: Thirty-six unique websites were identified. The mean total DISCERN score for all websites was 39.92 ± 12.44 (range = 18-62). No website achieved the maximum DISCERN score of 75. The mean JAMA and diverticulitis scores were 2.5 ± 1.08 (maximum possible score = 4) and 11.08 ± 4.17 (19 points possible) respectively. Fourteen (35.9%) and 20 (51.2%) did not provide the date of last update and authorship respectively. Thirty-three (84.6%) mentioned surgery as a treatment option; however, the majority (69.7%) did not describe the surgery or the possibility of a stoma. All except two described disease symptoms. Only ten (25.64%) provided information on when to seek further medical advice or help.

Conclusion: Web-based information on diverticulitis is of variable content and quality. The majority of top websites describe disease symptoms and aetiology; however, information to prompt seeking medical attention if required, descriptions of surgical procedures and the possibility of stoma creation are poorly described in the majority of websites. These findings should be highlighted to patients utilising the internet to obtain information on diverticulitis.
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http://dx.doi.org/10.1016/j.surge.2018.03.010DOI Listing
December 2018

Head and neck subcutaneous emphysema, a rare complication of iatrogenic perforation during colonoscopy: management review of reported cases from 2000-2016.

Expert Rev Gastroenterol Hepatol 2017 Sep 19;11(9):849-856. Epub 2017 Jul 19.

b Surgery , Mayo General Hospital , Castlebar , Ireland.

Introduction: Subcutaneous face and neck emphysema secondary to colonic perforation is a rare complication of colonoscopy. Presentation may be complicated by pneumothorax and/or respiratory distress. Evidence limited to case studies. Therefore, no management consensus of these rarely reported cases exists.

Methods: All cases published on PubMed between 1 January 2000-1 November 2016 reporting subcutaneous face and/or neck emphysema after colonoscopy are included. Management is discussed with trends identified. We report a case of a patient undergoing routine polypectomy who developed subcutaneous emphysema of the face, neck and thorax with a pneumothorax and pneumoretroperitoneum.

Results: 37 cases were found (mean age = 64.1 ± 15.09 years). The majority (n = 24) were managed non-operatively. Conservative and operative management had mean inpatient stays of 7.6 ± 4.65 and 19.5 +/- 21.62 days respectively. Sixteen cases had a concomitant pneumothorax with nine (56.3%) requiring decompression. No mortalities occurred.

Conclusion: An understanding of anatomy heightens awareness of the rare complication of face and/or neck surgical emphysema, secondary to pneumoretroperitoneum and pneumothorax, after perforation of the colon during endoscopy. Management remains controversial with expectant conservative bowel rest with antibiotics and operative intervention described. Conservative management had a shorter inpatient stay and was more common in younger patients.
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http://dx.doi.org/10.1080/17474124.2017.1351294DOI Listing
September 2017

Diverticulitis and Crohn's disease have distinct but overlapping tumor necrosis superfamily 15 haplotypes.

J Surg Res 2017 06 27;214:262-269. Epub 2017 Feb 27.

Division of Colon and Rectal Surgery, Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania. Electronic address:

Background: Diverticulitis (DD) and Crohn's disease (CD) have overlapping features including bowel structuring, inflammation, and infection. Tumor necrosis superfamily 15 (TNFSF15) is an immunoregulatory, anti-angiogenic gene. CD has been previously associated with a haplotype of five TNFSF15 single-nucleotide polymorphism alleles: rs3810936 (G allele), rs6478108 (A), rs6478109 (G), rs7848647 (G), and rs7869487 (A). We aimed to determine the TNFSF15 risk haplotype for DD versus controls with a subgroup analysis of youthful DD patients (aged ≤55 y) versus older controls (aged ≥55 y).

Methods: A total of 148 diverticulitis patients (90 aged ≤55 y) and 200 controls (87 aged ≥55 y) were genotyped using our custom-designed Illumina Veracode microarray chip. Genotypes from rs3810936, rs6478108, rs6478109, rs7848647, rs7869487 and two additional TNFSF15 single nucleotide polymorphisms, rs3810936 and rs11554257, were analyzed. PHASE version 2.1, R with HaploStats and the Broad Institute's Haploview program were used for statistics and imputed haplotype frequency. Permutation corrected for multiple comparisons.

Results: The CD GAGGA haplotype was significantly associated with diverticulitis (P = 0.03) in the all DD versus all controls comparison. A second haplotype, rs6478108 (A), rs6478109 (G), rs7869487 (A), and rs4263839 (G), was also associated with DD in this cohort (P = 0.025). A third haplotype rs6478108 (A), rs6478109 (G), rs7848647 (G) and rs7869487 (A), rs4263839 (G) was demonstrated in the DD < 55 versus controls >55 comparison (P = 0.045).

Conclusions: Distinct but overlapping TNFSF15 haplotypes were demonstrated in diverticulitis patients versus healthy controls when compared with the known Crohn's risk haplotype suggesting similar but distinct genetic predispositions. This study strengthens the role for a genetic predisposition to diverticulitis that involves the TNFSF15 gene.
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http://dx.doi.org/10.1016/j.jss.2017.02.030DOI Listing
June 2017

Human parechovirus sepsis induced coagulopathy in an infant.

Enferm Infecc Microbiol Clin (Engl Ed) 2018 Feb 17;36(2):143-144. Epub 2017 May 17.

Departmento de Biología Molecular e Ingeniería Bioquímica, Universidad Pablo Olavide, Sevilla, España.

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http://dx.doi.org/10.1016/j.eimc.2017.04.003DOI Listing
February 2018

Diverticular disease is associated with benign intra-abdominal cystic disease.

Expert Rev Gastroenterol Hepatol 2017 May 20;11(5):487-490. Epub 2017 Feb 20.

a Department of Surgery , The Galway Clinic , Galway , Ireland.

Background: Diverticular disease (DD) and hepatic and renal cysts have been linked with defects in collagen and dysfunctional matrix metalloproteinases.

Methods: Consecutive abdominal computed tomography scans between January-July 2015 were prospectively studied to determine a correlation between visceral cysts and DD. Patients with a sigmoid colectomy for pathology other than DD and scans in which DD and/or solid organs were not fully visualized were excluded. A subgroup analysis was performed on youthful DD patients (<55 years of age, n = 32) vs. older controls (>55, n = 213).

Results: 238 DD patients (50.8% male) and 369 controls (40.5% male, p = .02) were included. Incidence of visceral cystic disease in DD patients vs. controls was 71.4% vs. 22.5% (p < 0.00001). Renal cysts, present in 53.4% of the DD patients and 18.7% of the controls (p < .00001), were more common than hepatic cysts in both groups. Hepatic cyst prevalence was 8.8 vs. 2.4% (p = .0008). In the subgroup analysis, cystic disease was present in 56.2% of youthful DD patients vs. 29.1% of older controls (p = .004).

Conclusions: A significant association between cystic disease and DD was demonstrated overall and in subgroup analysis inclusive of youthful DD patients and older controls. These findings suggest a global defect in connective tissue integrity in DD patients.
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http://dx.doi.org/10.1080/17474124.2017.1294061DOI Listing
May 2017

A Radiologically Detected Intraperitoneal Foreign Body in a Patient Without Prior Surgery.

Am Surg 2017 Jan;83(1):e28-29

Department of Surgery, St. Luke's Hospital, Kilkenny, Ireland.

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January 2017

The RIPASA score is sensitive and specific for the diagnosis of acute appendicitis in a western population.

Int J Colorectal Dis 2017 Apr 15;32(4):491-497. Epub 2016 Dec 15.

Department of Surgery, St. Luke's Hospital, Kilkenny, Ireland.

Aim: The definitive diagnosis of acute appendicitis (AA) requires histopathological examination. Various clinical diagnostic scoring systems attempt to reduce negative appendectomy rates. The most commonly used in Western Europe and the USA is the Alvarado score. The Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) score achieves better sensitivity and specificity in Asian and Middle Eastern populations. We aimed to determine the diagnostic accuracy of the RIPASA score in Irish patients with AA.

Methods: All patients who presented to our institution with right iliac fossa pain and clinically suspected AA between January 1 and December 31, 2015, were indentified from our hospital inpatient enquiry database and retrospectively studied. Operating theatre records and histology reports confirmed those who underwent a non-elective operative procedure and the presence or absence of AA. SPSS version 22 was used for statistical analysis. Standard deviation is provided where appropriate.

Results: Two hundred eight patients were included in the study (106/51% male, mean age 22.7 ± 9.2 years). One hundred thirty-five (64.9%) had histologically confirmed AA (mean symptom duration = 36.19 ± 15.90 h). At a score ≥7.5, the previously determined score most likely associated with AA in Eastern populations, the RIPASA scoring system demonstrated a sensitivity of 85.39%, specificity of 69.86%, positive predictive value of 84.06%, negative predictive value of 72.86% and diagnostic accuracy of 80% in our cohort.

Conclusion: The RIPASA score is a useful tool to aid in the diagnosis of acute appendicitis in the Irish population. A score of ≥7.5 provides sensitivity and specificity exceeding that previously documented for the Alvarado score in Western populations. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: This is the first study evaluating the utility of the RIPASA score in predicting acute appendicitis in a Western population. At a value of 7.5, a cut-off score suggestive of appendicitis in the Eastern population, RIPASA demonstrated a high-sensitivity, specificity, positive predictive value and diagnostic accuracy in our cohort and was more accurate than the commonly used Alvarado score.
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http://dx.doi.org/10.1007/s00384-016-2713-4DOI Listing
April 2017

A severe penetrating cardiac injury in the absence of cardiac tamponade.

Interact Cardiovasc Thorac Surg 2017 02;24(2):286-287

Department of Cardiothoracic Surgery, University Hospital Galway, Galway, Ireland.

Penetrating cardiac injury is rare and frequently not survivable. Significant haemorrhage resulting in cardiac tamponade commonly ensues. Such cardiac tamponade is a clear clinical, radiological and sonographic indicator of significant underlying injury. In the absence of cardiac tamponade, diagnosis can be more challenging. In this case of a 26-year old sailor stabbed at sea, a significant pericardial effusion and cardiac tamponade did not occur despite an injury transversing the pericardium. Instead, the pericardial haemorrhage drained into the left pleural cavity resulting in a haemothorax. This case is notable due to a favourable outcome despite a delay in diagnosis due to a lack of pericardial effusion, a concomitant cerebrovascular event and a long delay from injury to appropriate medical treatment in the presence of a penetrating cardiac wound deep enough to cause a muscular ventricular septal defect and lacerate a primary chordae of the anterior mitral leaflet.
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http://dx.doi.org/10.1093/icvts/ivw342DOI Listing
February 2017

The 100 classic papers in ulcerative colitis: a bibliometric analysis.

Expert Rev Gastroenterol Hepatol 2016 Oct 22;10(10):1187-1195. Epub 2016 Aug 22.

c Division of Colon and Rectal Surgery, Milton Hershey Medical Center , Pennsylvania State College of Medicine , Hershey , PA , USA.

Background: The identification of the top 100 papers in ulcerative colitis (UC) using citation analysis provides a unique insight into the advancement of disease understanding and subsequent treatment innovations that have progressed over time.

Methods: The Thomson Reuters Web of Knowledge was used to identify the 100 most cited UC manuscripts. Title, first and senior authors, institution and department of first author, journal, country of origin, year and topic of each manuscript were analyzed.

Results: The top 100 manuscripts were published between 1955-2012. Thirty eight percent of the manuscripts originated from the US followed by the UK (26%). Genetics was the topic with the most publications (n = 27), followed by treatment (n = 22) and immunological pathways (n = 17). Truelove had the highest amount of authorships. The institutions with the highest number of publications were St. Mark's, London and the Radcliffe Infirmary.

Conclusion: This list of highly cited papers identifies the topics and authors that have made the most impact in the study of UC over the last century. This paper provides a reference of what could be considered as the most influential UC papers and serves as a reference of what comprises a 'highly citable' manuscript for both researchers and clinicians.
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http://dx.doi.org/10.1080/17474124.2016.1216786DOI Listing
October 2016

Gastropericardial fistula: radiologic findings and literature review.

J Surg Res 2016 06 15;203(1):174-82. Epub 2016 Mar 15.

Department of Diagnostic Radiology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina. Electronic address:

Background: Gastropericardial fistula, a rare condition characterized by an abnormal communication between the stomach and the pericardium, is an emergency as sequelae such as cardiac tamponade and sepsis may lead to hemodynamic instability and death. We aimed to summarize the surgical and radiologic findings of the reported cases published to date, describe their pertinent surgical history, and present an algorithm for diagnosis.

Methods: The Pubmed database was searched using the terms: gastropericardial, pericardiogastric, pneumopericardium, pericardial, and pneumopericardium with the term "fistula" added to each term. The search was limited to January 2000-October 2015 and English language publications.

Results: Thirty five cases were identified. The most common etiology was prior esophageal and/or gastric surgery (80% of cases; esophagectomy = 26%/gastrointestinal reflux disease associated surgery = 23%/bariatric surgery = 11%/partial gastrectomy = 6%/other = 20%). The average duration between presentation and surgery was 7.3 ± 6.2 years (SD). Radiology typically played a crucial role in diagnosis with computed tomography most commonly demonstrated to be the most appropriate modality to demonstrate the fistula and assist in surgical planning. Contrast studies were frequently helpful to confirm the diagnosis. Chest x-ray findings including pneumopericardium and pericardial thickening were contributory but nonspecific. Esophagoduodenoscopy characterized the fistula in cases where imaging was equivocal and may provide therapeutic options.

Conclusions: We present the clinical radiologic findings of the 35 cases of gastropericardial fistula reported. This is the first literature review of gastropericardial fistula to focus on the effectiveness of these various diagnostic modalities and to present an algorithm for diagnosis.
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http://dx.doi.org/10.1016/j.jss.2016.03.015DOI Listing
June 2016

Outcomes of early ileocolectomy after percutaneous drainage for perforated ileocolic Crohn's disease.

Am J Surg 2016 Oct 12;212(4):728-734. Epub 2016 May 12.

Department of Surgery, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA 17033-0850, USA. Electronic address:

Background: The optimal treatment for an intra-abdominal abscess/infection secondary to perforating ileocolic Crohn's disease (PCD) is unclear.

Methods: Forty-seven consecutive PCD patients treated via an institutional protocol of ileocolectomy after a 7-day period of percutaneous abscess drainage were retrospectively compared with 160 consecutive patients who underwent an elective ileocolectomy for Crohn's disease (ECD) between 1992 and 2014. Outcomes were compared using univariate analysis and propensity score matching.

Results: Univariate analysis demonstrated significant differences in ileostomy rates (PCD: 48.9% vs ECD: 18.8%; P = .001), 30-day readmissions (PCD: 38.3% vs ECD: 18.8%; P = .01), and overall 30-day postoperative complications (PCD: 29.8% vs ECD: 15%; P = .03). After matching, a statistically significant difference was retained in ileostomy rates (P = .02) and 30-day readmissions (P = .01).

Conclusions: Early operative intervention after percutaneous drainage in perforating CD may be associated with a high incidence of diversions and readmissions.
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http://dx.doi.org/10.1016/j.amjsurg.2016.01.044DOI Listing
October 2016

Laparoscopic total extraperitoneal repair of preoperatively diagnosed bilateral obturator and incidental bilateral femoral herniae.

BMJ Case Rep 2016 Apr 25;2016. Epub 2016 Apr 25.

Department of Surgery, St Luke's Hospital Kilkenny, Kilkenny, Ireland.

Obturator hernia (OH), a rare type of hernia, is associated with high morbidity and mortality. Diagnosis is often delayed as clinical symptoms are typically non-specific. OH is frequently associated with other occult inguinopelvic herniae. Early diagnosis is vital to decrease morbidity and mortality. We report the case of a 75-year-old woman who presented to the surgical outpatients' department with non-specific bilateral groin pain radiating to the thighs. CT of the pelvis demonstrated bilateral OH with no radiological evidence of bowel obstruction. Semiurgent elective laparoscopic total extraperitoneal mesh repair was performed. Intraoperative findings confirmed bilateral obturator herniae as well as incidental bilateral femoral herniae. This case highlights the need for a high index of suspicion for such concomitant hernias that, in the presence of OH, may only be identified intraoperatively.
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http://dx.doi.org/10.1136/bcr-2016-214978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4854135PMC
April 2016

The 100 most influential manuscripts in colorectal cancer: A bibliometric analysis.

Surgeon 2016 Dec 16;14(6):327-336. Epub 2016 Apr 16.

Department of Surgery, Galway Clinic, Galway, Ireland; The Royal College of Surgeons Ireland, Dublin, Ireland.

Purpose: Bibliometric analysis highlights the key topics and studies which have led to the current understanding and treatment of a disease of interest. In this original article we analyze the 100 most cited manuscripts in the field of colorectal cancer (CRC).

Materials And Methods: The Thomson Reuters Web of Science database with the search terms 'colorectal cancer,' 'colorectal cancer surgery,' 'colon cancer,' 'rectal cancer,' 'colorectal carcinoma,' 'colon carcinoma,' 'rectal carcinoma' and/or 'colonoscopy' was used to identify the manuscripts for the study. Only full length manuscripts were included. The 100 most cited papers were identified and further analyzed by topic, journal, author, year and institution. The journals' 5 year impact factor and Eigenfactor scores were recorded.

Results: 146,833 eligible papers were returned. Within the top 100 cited manuscripts, the most studied topic was genetics in CRC (n = 41), followed by chemotherapy (n = 20) and surgical management (n = 7). The most cited paper authored by Fearon et al. (7850 citations) focused on genetic models of tumorgenesis. The NEJM published the highest number of papers (n = 23 with 42,576 citations). The country and year with the greatest number of publications were the USA (n = 62) and 2004 (n = 13) respectively.

Conclusion: The most cited manuscripts highlighted in the current work describe the genetic, immunologic, basic science and surgical techniques that have resulted in the current understanding and treatment of CRC. The majority of these works were published in high impact journals and have been cited at least 900 times each reflecting their quality and influence. This work provides a reference of what could be considered as the most influential papers in CRC and serves as a reference for researchers and clinicians as to what makes a 'citable' paper.
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http://dx.doi.org/10.1016/j.surge.2016.03.001DOI Listing
December 2016

Is a diverting ostomy needed in mid-high rectal cancer patients undergoing a low anterior resection after neoadjuvant chemoradiation? An NSQIP analysis.

Surgery 2015 Sep 23;158(3):686-91. Epub 2015 May 23.

Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA.

Introduction: A diverting stoma is often performed at the time of low anterior resection (LAR) for rectal cancer after neoadjuvant chemoradiation (nCRT) to protect the anastomosis. The aim of this study was to compare surgical outcomes in large cohorts of mid-high rectal cancer patients undergoing LAR after nCRT with and without a diverting stoma.

Methods: Patients undergoing LAR for rectal cancer (ICD-9 diagnosis code 154.1) after nCRT were identified from the American College of Surgeons National Surgical Quality Improvement Program database records from 2005 to 2012. Using Current Procedural Terminology (CPT) codes for LAR for mid-high rectal tumors, patients were stratified into diverting stoma (CPT: 44146, 44208) or no diverting stoma (CPT: 44145, 44207) cohorts. Emergency resection, stage IV disease, and permanent end colostomy patients were excluded.

Results: We included 1,406 patients in the analysis. All patients received nCRT; 607 (43%) received a diverting stoma and 799 (57%) were not diverted. The diverted group was more likely to have a higher body mass index (28.3 vs 27.4 kg/m(2); P = .02) and hypertension (46% vs 39%; P = .002). Otherwise, the group demographics and comorbidities were comparable. Overall morbidity was 28% for the entire cohort with no differences in deep organ space infection, sepsis and septic shock, unplanned reoperation, duration of stay, or overall mortality between the groups.

Conclusion: Diverting stoma does not decrease mortality or infectious complications in mid-high rectal cancer patients undergoing LAR after nCRT. The decision to construct a protective stoma should not be driven solely on the receipt of nCRT.
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http://dx.doi.org/10.1016/j.surg.2015.02.026DOI Listing
September 2015

Surgical diverticulitis is not associated with defects in the expression of wound healing genes.

Int J Colorectal Dis 2015 Sep 24;30(9):1247-54. Epub 2015 May 24.

Department of Surgery, Division of Colon and Rectal Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, 17033-0850, USA.

Purpose: The development of diverticuli may represent defects in collagen vascular tissue integrity possibly from a genetic predisposition. We evaluated the tissue expression of wound healing genes in sigmoid tissue from youthful patients undergoing surgery for diverticulitis and thus would more likely suffer from a genetic predisposition (SD mean age 39 ± 0.9) versus controls in the form of patients over the age of 50 (mean age 52.9 ± 10.5 years) without evidence of diverticular disease.

Methods: The mRNA expression of 84 genes associated with the extracellular matrix, cellular adhesion, growth factors, inflammatory cytokines, and signal transduction was evaluated in 16 SD and 15 control tissues using a Qiagen Wound Healing Array. Vitronectin, the gene protein with the highest potential significance on raw analysis, was further investigated using a Taqman assay with an additional 11 SD (total n = 27) and four control (total n = 19) samples. Statistics were by Student's t and Mann-Whitney tests with Bonferroni correction.

Results: No significant differences in mRNA expression between the SD and control tissue in the 84 measured genes were demonstrated after correction. Vitronectin mRNA expression was downregulated 2.7-fold in SD tissue vs. tissue from non-neoplastic control patients (p = 0.001 raw/0.08 corrected). However, on vitronectin TaqMan analysis, no difference in expression was seen in SD vs. all controls or in all subset comparisons.

Conclusions: The lack of significant alteration in mRNA expression of traditionally associated wound healing genes/proteins in young SD patients suggests that such genes play a minor role in the genetic predisposition to youthful diverticulitis.
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http://dx.doi.org/10.1007/s00384-015-2263-1DOI Listing
September 2015

Risk factors for the development of an incisional hernia after sigmoid resection for diverticulitis: an analysis of 33 patients, operative and disease-associated factors.

Am Surg 2015 May;81(5):492-7

Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, Pennsylvania, USA.

Incisional hernia (IH) is a relatively common sequelae of sigmoidectomy for diverticulitis. The aim of this study was to investigate factors that may predict IH in diverticulitis patients. Two hundred and one diverticulitis patients undergoing sigmoidectomy between January 2002 and December 2012 were identified (mean follow-up 5.15 ± 2.33 years). Patients with wound infections were excluded. Thirteen patient-associated, three diverticular disease-related, and 17 operative variables were evaluated in patients with and without IH. Volumetric fat was measured on preoperative CTs. Fischer's exact, χ(2), and Mann-Whitney tests and multivariate regression analysis were used for statistics. Thirty-four (17%) patients had an IH. On multivariate analysis, wound packing (OR 3.4, P = 0.017), postoperative nonwound infection (OR 7.4, P = 0.014), and previous hernia (OR 3.6, P = 0.005) were as independent predictors of IH. Fifteen of 34 (44%) patients who developed a hernia had a history of prior hernia. Of 33 potential risk factors analyzed, including smoking, chronic obstructive pulmonary disease, and obesity, the only patient factor present preoperatively associated with increased risk of a postsigmoidectomy hernia after multivariate analysis was a history of a previous hernia. Preoperative identification of patients with a history of hernia offers the opportunity to employ measures to decrease the likelihood of IH.
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May 2015
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