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Nagarur A, Pierce TT, Fenves AZ, Witkowski ER, Gold NB. Case 30-2023: A 50-Year-Old Woman with Confusion. N Engl J Med 2023; 389:1221-1230. [PMID: 37754288 DOI: 10.1056/nejmcpc2300907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Affiliation(s)
- Amulya Nagarur
- From the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Massachusetts General Hospital, and the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Harvard Medical School - both in Boston
| | - Theodore T Pierce
- From the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Massachusetts General Hospital, and the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Harvard Medical School - both in Boston
| | - Andrew Z Fenves
- From the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Massachusetts General Hospital, and the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Harvard Medical School - both in Boston
| | - Elan R Witkowski
- From the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Massachusetts General Hospital, and the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Harvard Medical School - both in Boston
| | - Nina B Gold
- From the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Massachusetts General Hospital, and the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Harvard Medical School - both in Boston
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Osganian SA, Subudhi S, Masia R, Drescher HK, Bartsch LM, Chicote ML, Chung RT, Gee DW, Witkowski ER, Bredella MA, Lauer GM, Corey KE, Dichtel LE. Expression of IGF-1 receptor and GH receptor in hepatic tissue of patients with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. Growth Horm IGF Res 2022; 65:101482. [PMID: 35780715 PMCID: PMC9885486 DOI: 10.1016/j.ghir.2022.101482] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/02/2022] [Accepted: 06/12/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The GH and IGF-1 axis is a candidate disease-modifying target in nonalcoholic fatty liver disease (NAFLD) given its lipolytic, anti-inflammatory and anti-fibrotic properties. IGF-1 receptor (IGF-1R) and GH receptor (GHR) expression in adult, human hepatic tissue is not well understood across the spectrum of NAFLD severity. Therefore, we sought to investigate hepatic IGF-1R and GHR expression in subjects with NAFLD utilizing gene expression analysis (GEA) and immunohistochemistry (IHC). DESIGN GEA (n = 318) and IHC (n = 30) cohorts were identified from the Massachusetts General Hospital NAFLD Tissue Repository. GEA subjects were categorized based on histopathology as normal liver histology (NLH), steatosis only (Steatosis), nonalcoholic steatohepatitis (NASH) without fibrosis (NASH F0), and NASH with fibrosis (NASH F1-4) with GEA by the Nanostring nCounter assay. IHC subjects were matched for age, body mass index (BMI), sex, and diabetic status across three groups (n = 10 each): NLH, Steatosis, and NASH with fibrosis (NASH F1-3). IHC for IGF-1R, IGF-1 and GHR was performed on formalin-fixed, paraffin-embedded hepatic tissue samples. RESULTS IGF-1R gene expression did not differ across NAFLD severity while IGF-1 gene expression decreased with increasing NAFLD severity, including when controlled for BMI and age. GHR expression did not differ by severity of NAFLD based on GEA or IHC. CONCLUSIONS IGF-1R and GHR expression levels were not significantly different across NAFLD disease severity. However, expression of IGF-1 was lower with increasing severity of NAFLD. Additional research is needed regarding the contribution of the GH/IGF-1 axis to the pathophysiology of NAFLD and NASH.
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Affiliation(s)
- Stephanie A Osganian
- Liver Center, Division of Gastroenterology, Massachusetts General Hospital (MGH), Boston, MA, USA
| | - Sonu Subudhi
- Liver Center, Division of Gastroenterology, Massachusetts General Hospital (MGH), Boston, MA, USA; Harvard Medical School (HMS), Boston, MA, USA
| | - Ricard Masia
- Harvard Medical School (HMS), Boston, MA, USA; Department of Pathology, MGH, Boston, MA, USA
| | - Hannah K Drescher
- Liver Center, Division of Gastroenterology, Massachusetts General Hospital (MGH), Boston, MA, USA; Harvard Medical School (HMS), Boston, MA, USA
| | - Lea M Bartsch
- Liver Center, Division of Gastroenterology, Massachusetts General Hospital (MGH), Boston, MA, USA; Harvard Medical School (HMS), Boston, MA, USA
| | | | - Raymond T Chung
- Liver Center, Division of Gastroenterology, Massachusetts General Hospital (MGH), Boston, MA, USA; Harvard Medical School (HMS), Boston, MA, USA
| | - Denise W Gee
- Harvard Medical School (HMS), Boston, MA, USA; Department of Surgery, MGH, Boston, MA, USA
| | - Elan R Witkowski
- Harvard Medical School (HMS), Boston, MA, USA; Department of Surgery, MGH, Boston, MA, USA
| | - Miriam A Bredella
- Harvard Medical School (HMS), Boston, MA, USA; Department of Radiology, Division of Musculoskeletal Radiology and Interventions, MGH, Boston, MA, USA
| | - Georg M Lauer
- Liver Center, Division of Gastroenterology, Massachusetts General Hospital (MGH), Boston, MA, USA; Harvard Medical School (HMS), Boston, MA, USA
| | - Kathleen E Corey
- Liver Center, Division of Gastroenterology, Massachusetts General Hospital (MGH), Boston, MA, USA; Harvard Medical School (HMS), Boston, MA, USA
| | - Laura E Dichtel
- Harvard Medical School (HMS), Boston, MA, USA; Neuroendocrine Unit, MGH, Boston, MA, USA.
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Corey KE, Pitts R, Lai M, Loureiro J, Masia R, Osganian SA, Gustafson JL, Hutter MM, Gee DW, Meireles OR, Witkowski ER, Richards SM, Jacob J, Finkel N, Ngo D, Wang TJ, Gerszten RE, Ukomadu C, Jennings LL. ADAMTSL2 protein and a soluble biomarker signature identify at-risk non-alcoholic steatohepatitis and fibrosis in adults with NAFLD. J Hepatol 2022; 76:25-33. [PMID: 34600973 PMCID: PMC8688231 DOI: 10.1016/j.jhep.2021.09.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS Identifying fibrosis in non-alcoholic fatty liver disease (NAFLD) is essential to predict liver-related outcomes and guide treatment decisions. A protein-based signature of fibrosis could serve as a valuable, non-invasive diagnostic tool. This study sought to identify circulating proteins associated with fibrosis in NAFLD. METHODS We used aptamer-based proteomics to measure 4,783 proteins in 2 cohorts (Cohort A and B). Targeted, quantitative assays coupling aptamer-based protein pull down and mass spectrometry (SPMS) validated the profiling results in a bariatric and NAFLD cohort (Cohort C and D, respectively). Generalized linear modeling-logistic regression assessed the ability of candidate proteins to classify fibrosis. RESULTS From the multiplex profiling, 16 proteins differed significantly by fibrosis in cohorts A (n = 62) and B (n = 98). Quantitative and robust SPMS assays were developed for 8 proteins and validated in Cohorts C (n = 71) and D (n = 84). The A disintegrin and metalloproteinase with thrombospondin motifs like 2 (ADAMTSL2) protein accurately distinguished non-alcoholic fatty liver (NAFL)/non-alcoholic steatohepatitis (NASH) with fibrosis stage 0-1 (F0-1) from at-risk NASH with fibrosis stage 2-4, with AUROCs of 0.83 and 0.86 in Cohorts C and D, respectively, and from NASH with significant fibrosis (F2-3), with AUROCs of 0.80 and 0.83 in Cohorts C and D, respectively. An 8-protein panel distinguished NAFL/NASH F0-1 from at-risk NASH (AUROCs 0.90 and 0.87 in Cohort C and D, respectively) and NASH F2-3 (AUROCs 0.89 and 0.83 in Cohorts C and D, respectively). The 8-protein panel and ADAMTSL2 protein had superior performance to the NAFLD fibrosis score and fibrosis-4 score. CONCLUSION The ADAMTSL2 protein and an 8-protein soluble biomarker panel are highly associated with at-risk NASH and significant fibrosis; they exhibited superior diagnostic performance compared to standard of care fibrosis scores. LAY SUMMARY Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of liver disease worldwide. Diagnosing NAFLD and identifying fibrosis (scarring of the liver) currently requires a liver biopsy. Our study identified novel proteins found in the blood which may identify fibrosis without the need for a liver biopsy.
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Affiliation(s)
- Kathleen E. Corey
- Division of Gastroenterology, Massachusetts General Hospital (MGH) and Harvard Medical School (HMS), Boston, MA, USA
| | - Rebecca Pitts
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Michelle Lai
- Division of Hepatology, Beth Israel Deaconess Hospital (BIDMC) and HMS, Boston, MA, USA
| | - Joseph Loureiro
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Ricard Masia
- Department of Pathology, MGH and HMS, Boston, MA, USA
| | - Stephanie A. Osganian
- Division of Gastroenterology, Massachusetts General Hospital (MGH) and Harvard Medical School (HMS), Boston, MA, USA
| | - Jenna L. Gustafson
- Division of Gastroenterology, Massachusetts General Hospital (MGH) and Harvard Medical School (HMS), Boston, MA, USA
| | | | | | | | | | | | - Jaison Jacob
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Nancy Finkel
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Debby Ngo
- Department of Pulmonary/Critical Care, Cardiovascular Institute, BIDMC and HMS, Boston, MA, USA
| | - Thomas J Wang
- Department of Cardiology, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Robert E. Gerszten
- Division of Cardiovascular Medicine and Cardiovascular Institute, BIDMC and HMS, Boston, MA, USA
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Jung JJ, Park AK, Witkowski ER, Hutter MM. Comparison of Short-term Safety of One Anastomosis Gastric Bypass to Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in the United States: 341 cases from MBSAQIP-accredited Centers. Surg Obes Relat Dis 2021; 18:326-334. [PMID: 34896012 DOI: 10.1016/j.soard.2021.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/22/2021] [Accepted: 11/07/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND One anastomosis gastric bypass (OAGB) is the third most common (4%) primary bariatric procedure worldwide but is seldom performed in the United States and is currently under consideration for endorsement by the American Society for Metabolic and Bariatric Surgery. Evidence from the United States on safety of OAGB compared to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) is limited. OBJECTIVE To compare the short-term safety outcomes of the three primary bariatric procedures. SETTING Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited hospitals in the United States and Canada. METHODS Using the 2015-2019 MBSAQIP database, we compared the safety outcomes of adult patients who underwent primary laparoscopic OAGB, RYGB, and SG. Exclusion criteria included age over 80 years, emergency operation, conversion, and incomplete follow-up. The primary outcome was 30-day overall complication. Secondary outcomes were 30-day surgical and medical complications and hospitalization length. RESULTS A total of 341 patients underwent primary OAGB. Using propensity scores, we matched the OAGB cohort 1:1 with two cohorts of similar baseline characteristics who underwent RYGB and SG, respectively. The OAGB cohort had a lower overall complication rate than the RYGB cohort (6.7% versus12.3%, P = .02) and a similar rate to the SG cohort (5.0%, P = .43). The OAGB cohort had a similar rate of surgical complication to the RYGB cohort (5.0% versus 8.5%, P = .1) and a higher rate than the SG group (1.2%, P = .009). The OAGB cohort had a shorter median hospitalization than the RYGB cohort (1 d [interquartile range (IQR) 1-2 d] versus 2 d [IQR 1-2 d], P < .001) and a similar hospitalization length to the SG cohort ([1-2 d], P = .46). CONCLUSION Using the largest and the most current U.S. data, this study demonstrated that the short-term safety profile of primary OAGB is acceptable, but future studies should determine the long-term safety.
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Affiliation(s)
- James J Jung
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; Department of Surgery, University of Toronto, Toronto, Canada.
| | - Albert K Park
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Elan R Witkowski
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Matthew M Hutter
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Subudhi S, Drescher HK, Dichtel LE, Bartsch LM, Chung RT, Hutter MM, Gee DW, Meireles OR, Witkowski ER, Gelrud L, Masia R, Osganian SA, Gustafson JL, Rwema S, Bredella MA, Bhatia SN, Warren A, Miller KK, Lauer GM, Corey KE. Distinct Hepatic Gene-Expression Patterns of NAFLD in Patients With Obesity. Hepatol Commun 2021; 6:77-89. [PMID: 34558849 PMCID: PMC8710788 DOI: 10.1002/hep4.1789] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/13/2021] [Indexed: 02/06/2023] Open
Abstract
Approaches to manage nonalcoholic fatty liver disease (NAFLD) are limited by an incomplete understanding of disease pathogenesis. The aim of this study was to identify hepatic gene‐expression patterns associated with different patterns of liver injury in a high‐risk cohort of adults with obesity. Using the NanoString Technologies (Seattle, WA) nCounter assay, we quantified expression of 795 genes, hypothesized to be involved in hepatic fibrosis, inflammation, and steatosis, in liver tissue from 318 adults with obesity. Liver specimens were categorized into four distinct NAFLD phenotypes: normal liver histology (NLH), steatosis only (steatosis), nonalcoholic steatohepatitis without fibrosis (NASH F0), and NASH with fibrosis stage 1‐4 (NASH F1‐F4). One hundred twenty‐five genes were significantly increasing or decreasing as NAFLD pathology progressed. Compared with NLH, NASH F0 was characterized by increased inflammatory gene expression, such as gamma‐interferon‐inducible lysosomal thiol reductase (IFI30) and chemokine (C‐X‐C motif) ligand 9 (CXCL9), while complement and coagulation related genes, such as C9 and complement component 4 binding protein beta (C4BPB), were reduced. In the presence of NASH F1‐F4, extracellular matrix degrading proteinases and profibrotic/scar deposition genes, such as collagens and transforming growth factor beta 1 (TGFB1), were simultaneously increased, suggesting a dynamic state of tissue remodeling. Conclusion: In adults with obesity, distinct states of NAFLD are associated with intrahepatic perturbations in genes related to inflammation, complement and coagulation pathways, and tissue remodeling. These data provide insights into the dynamic pathogenesis of NAFLD in high‐risk individuals.
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Affiliation(s)
- Sonu Subudhi
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Hannah K Drescher
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Laura E Dichtel
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Lea M Bartsch
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Raymond T Chung
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Denise W Gee
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ozanan R Meireles
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Elan R Witkowski
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Louis Gelrud
- Department of Medicine, St. Mary's Hospital Bon Secours, Richmond, VA, USA
| | - Ricard Masia
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephanie A Osganian
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jenna L Gustafson
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Steve Rwema
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Miriam A Bredella
- Division of Musculoskeletal Radiology and Interventions, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sangeeta N Bhatia
- Ludwig Center for Molecular Oncology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Andrew Warren
- Ludwig Center for Molecular Oncology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Georg M Lauer
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kathleen E Corey
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Udelsman BV, Corey K, Hutter MM, Chang DC, Witkowski ER. Use of noninvasive scores for advanced liver fibrosis can guide the need for hepatic biopsy during bariatric procedures. Surg Obes Relat Dis 2020; 17:292-298. [PMID: 33153965 DOI: 10.1016/j.soard.2020.09.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/22/2020] [Accepted: 09/29/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with obesity are at increased risk for nonalcoholic fatty liver disease (NAFLD). The effectiveness of noninvasive screening tests for ruling out advanced fibrosis (stage 3-4) is unknown. OBJECTIVES To determine the prevalence of advanced fibrosis in patients undergoing routine liver biopsy during bariatric surgery and assess the effectiveness of existing noninvasive risk calculators. SETTING Academic medical center in the United States. METHODS Routine liver biopsies were obtained during first-time bariatric surgery (January 2001-December 2017). Patient demographic characteristics, co-morbidities, and preoperative laboratory values were compiled. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were compared between 3 noninvasive risk calculators for advanced fibrosis: the fibrosis-4 index, NAFLD fibrosis score, and aminotransferase-to-platelet ratio index (APRI). RESULTS Among 2465 patients, the prevalence of advanced fibrosis (stage 3-4) was 3.4%. The mean age was 45.5 years, and the mean body mass index was 46.8. The sensitivity of noninvasive risk calculators ranged from 85% (NAFLD fibrosis score) to 24% (APRI). The NAFLD fibrosis score performed best in screening out advanced fibrosis, with an NPV of 99%. The PPV ranged from 9% to 65%. In this study cohort, the use of the NALFD fibrosis score correctly ruled out advanced fibrosis in 893 (36%) patients, with 13 false negatives. CONCLUSIONS The prevalence of advanced fibrosis in individuals undergoing routine first-time bariatric procedures is 3.4%. Use of the NALFD fibrosis score can rule out advanced fibrosis in one-third of this population, and guide surgical decision-making.
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Affiliation(s)
- Brooks V Udelsman
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - Kathleen Corey
- Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Elan R Witkowski
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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7
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Udelsman BV, Corey KE, Lindvall C, Gee DW, Meireles OR, Hutter MM, Chang DC, Witkowski ER. Risk factors and prevalence of liver disease in review of 2557 routine liver biopsies performed during bariatric surgery. Surg Obes Relat Dis 2019; 15:843-849. [PMID: 31014948 DOI: 10.1016/j.soard.2019.01.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/21/2019] [Accepted: 01/30/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Obesity is a known risk factor for nonalcoholic fatty liver disease (NAFLD). However, among individuals undergoing bariatric surgery, the prevalence and risk factors for NAFLD, as well as distinct phenotypes of steatosis, nonalcoholic steatohepatitis (NASH), and fibrosis remain incompletely understood. OBJECTIVES To determine the prevalence and risk factors for steatosis, NASH, and fibrosis in individuals undergoing routine bariatric surgery. SETTING Academic medical center in the United States. METHODS Liver wedge biopsies were performed at the time of surgery between 2001 and 2017. Pathology reports were reviewed, and individuals were grouped by NAFLD phenotype. Covariates including demographic characteristics, co-morbidities, and preoperative laboratory values were compared between groups using Student's t test, Pearson's χ2, and logistic regression. RESULTS Liver biopsies were obtained in 97.7% of first-time bariatric procedures, representing 2557 patients. Mean age was 45.6 years, mean body mass index was 46.7, and most were non-Hispanic white (76.1%) and female (71.6%). On histologic review 61.2% had steatosis and 30.9% NASH. Fibrosis was identified in 29.3% of individuals, and 7.8% had stage ≥2 fibrosis. On logistic regression, elevated aspartate aminotransferase (odds ratio [OR] 1.87; P < .001) and elevated alanine aminotransferase (OR 1.62; P < .001) were independently associated with fibrosis. Elevated hemoglobin A1C of 5.7% to 6.5% (OR 1.29; P < .01) and >6.5% (OR 3.23; P < .001) were also associated with fibrosis. A similar trend was seen for NASH. CONCLUSIONS NASH and/or fibrosis is present in nearly one third of patients undergoing routine bariatric surgery. Risk factors include diabetes, elevated liver enzymes, and diabetes. Risk assessment and aggressive screening should be considered in patients undergoing bariatric surgery.
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Affiliation(s)
- Brooks V Udelsman
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Kathleen E Corey
- Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Denise W Gee
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Ozanan R Meireles
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Elan R Witkowski
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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8
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Bliss LA, Witkowski ER, Yang CJ, Tseng JF. Outcomes in operative management of pancreatic cancer. J Surg Oncol 2014; 110:592-8. [PMID: 25111970 DOI: 10.1002/jso.23744] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 06/18/2014] [Indexed: 12/18/2022]
Abstract
Pancreatic cancer is a highly lethal malignancy that often presents at an advanced stage. Surgical resection can prolong survival and offers the only potential for cure. However, pancreatectomy is associated with significant morbidity and mortality. This article reviews perioperative outcomes, post-resection long-term survival, and innovations in the surgical management of pancreatic cancer.
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Affiliation(s)
- Lindsay A Bliss
- Department of Surgery and Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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9
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Collins CE, Witkowski ER, Flahive JM, Anderson FA, Santry HP. Effect of preinjury warfarin use on outcomes after head trauma in Medicare beneficiaries. Am J Surg 2014; 208:544-549.e1. [PMID: 25129426 DOI: 10.1016/j.amjsurg.2014.05.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 04/17/2014] [Accepted: 05/02/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Elderly Americans are at increased risk of head trauma, particularly fall related. The effect of warfarin on head trauma outcomes remains controversial. METHODS Medicare beneficiaries with head injuries from 2009 to 2011 were identified by International Classification of Diseases (ICD)-9 code. Preinjury warfarin use was determined using Part D claims. Multiple logistic regression models determined the association of preinjury warfarin on need for hospitalization, intensive care unit care, and occurrence of intracranial hemorrhage. Association between warfarin and in-hospital mortality was assessed using a Cox proportional hazard model. RESULTS Of 11,078 head injured patients, 5.2% were injured while on warfarin. Preinjury warfarin increased the odds of intracranial hemorrhage by 40% and doubled the risk of 30-day in-hospital mortality after adjusting for demographic and clinical factors. CONCLUSIONS Warfarin at the time of head injury increases the risk of adverse outcomes in Medicare beneficiaries with head injuries. Caution should be used when initiating anticoagulation in elderly Americans at risk for trauma.
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Affiliation(s)
- Courtney E Collins
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Elan R Witkowski
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Julie M Flahive
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Fred A Anderson
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Heena P Santry
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA.
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Bliss LA, Yang CJ, Miksad RA, Tawa NE, Witkowski ER, Ng SC, Critchlow JF, Tseng JF. Totally implantable venous access device use in pancreatic cancer: A national analysis. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.e15188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Lindsay A. Bliss
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Catherine J. Yang
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | | | | | - Sing Chau Ng
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Jennifer F. Tseng
- Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
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Ragulin-Coyne E, Witkowski ER, Chau Z, Wemple D, Ng SC, Santry HP, Shah SA, Tseng JF. National trends in pancreaticoduodenal trauma: interventions and outcomes. HPB (Oxford) 2014; 16:275-81. [PMID: 23869407 PMCID: PMC3945854 DOI: 10.1111/hpb.12125] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 03/28/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Pancreaticoduodenal trauma (PDT) is associated with substantial mortality and morbidity. In this study, contemporary trends were analysed using national data. METHODS The Nationwide Inpatient Sample for 1998-2009 was queried for patients with PDT. Interventions including any operation (Any-Op) and pancreas-specific surgery (PSURG) were identified. Trends in treatment and outcomes were determined [complications, length of stay (LoS), mortality] for the Any-Op, PSURG and non-operative (Non-Op) groups. Analyses included chi-squared tests, Cochran-Armitage trend tests and logistic regression. RESULTS A total of 27 216 patients (nationally weighted) with PDT were identified. Over time, the frequency of PDT increased by 8.3%, whereas the proportion of patients submitted to PSURG declined (from 21.7% to 19.8%; P = 0.0004) and the percentage of patients submitted to non-operative management increased (from 56.7% to 59.1%; P = 0.01). In the Non-Op group, mortality decreased from 9.7% to 8.6% (P < 0.001); morbidity and LoS remained unchanged at ∼40% and ∼12 days, respectively. In the PSURG group, mortality remained stable at ∼15%, complications increased from 50.2% to 71.8% (P < 0.0001) and LoS remained stable at ∼21 days. For all PDT patients, significant independent predictors of mortality included: the presence of combined pancreatic and duodenal injuries; penetrating trauma, and age >50 years. Having any operation (Any-Op) was associated with mortality, but PSURG was not a predictor of death. CONCLUSIONS The utilization of operations for PDT has declined without affecting mortality, but operative morbidity increased significantly over the 12 years to 2009. The development of an evidence-based approach to invasive manoeuvres and an early multidisciplinary approach involving pancreatic surgeons may improve outcomes in patients with these morbid injuries.
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Affiliation(s)
- Elizaveta Ragulin-Coyne
- Department of Surgery, Surgical Outcomes Analysis and Research (SOAR), University of Massachusetts Medical SchoolWorcester, MA, USA
| | - Elan R Witkowski
- Department of Surgery, Surgical Outcomes Analysis and Research (SOAR), University of Massachusetts Medical SchoolWorcester, MA, USA
| | - Zeling Chau
- Department of Surgery, Surgical Outcomes Analysis and Research (SOAR), University of Massachusetts Medical SchoolWorcester, MA, USA
| | - Daniel Wemple
- Department of Surgery, Surgical Outcomes Analysis and Research (SOAR), University of Massachusetts Medical SchoolWorcester, MA, USA
| | - Sing Chau Ng
- Department of Surgery, Surgical Outcomes Analysis and Research (SOAR), University of Massachusetts Medical SchoolWorcester, MA, USA
| | - Heena P Santry
- Department of Surgery, Surgical Outcomes Analysis and Research (SOAR), University of Massachusetts Medical SchoolWorcester, MA, USA
| | - Shimul A Shah
- Department of Surgery, Surgical Outcomes Analysis and Research (SOAR), University of Massachusetts Medical SchoolWorcester, MA, USA
| | - Jennifer F Tseng
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA,Correspondence Jennifer F. Tseng, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Stoneman 9, Boston, MA 02215, USA. Tel: + 1 617 667 3746. Fax: + 1 617 667 7756. E-mail:
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12
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Bliss LA, Chau Z, Yang CJ, Smith JK, Witkowski ER, Ragulin-Coyne E, Ng SC, Critchlow JF, Moser AJ, Tseng JF. Utilization of laparoscopy for resections of stomach and esophagus cancers: Is hospital the deciding factor? J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.3_suppl.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
86 Background: Foregut surgery is technically complex. Outcomes for such high-stakes operations receive increasing scrutiny and the use of minimally invasive approaches has been further adopted. This study aims to determine national trends in laparoscopy utilization and patient outcomes for potentially curative cancer resections of the esophagus and stomach. Methods: Retrospective review of all esophageal and gastric cancer resections in the Nationwide Inpatient Sample during 1998 to 2011. Univariate analyses of sex, race, admission status, Elixhauser comorbidity score, year, insurance, hospital characteristics, procedure, and center volume were performed by chi-square. Cochran-Armitage test was used for trends. Logistic regressions were used to model inpatient mortality, complications and laparoscopy. Results: From 1998 to 2011, 120,527 and 25,540 patients (nationally-weighted records) underwent gastrectomies and esophagectomies for cancer. From early (1998-2002) to late (2008-2011) study years, inpatient mortality decreased from 6.69% to 3.88% (<0.0001) and complications increased from 27.41% to 31.63% (<0.0001) for gastrectomy. Similarly, inpatient mortality decreased from 9.75% to 5.53% (<0.0001) and complications increased from 37.69% to 43.07% (<0.0001) for esophagectomy. Use of laparoscopy in gastrectomy increased from 1.64% to 5.89% (p <0.0001) and in esophagectomy from 0.80% to 5.74% (<0.0001). Patients undergoing laparoscopy had lower inpatient mortality (3.13% vs. 5.96%, p=0.0010) and were less likely to experience complications (26.20% vs. 31.47%, p=0.0121). After adjustment, independent predictors of the use of laparoscopy included elective admission, female sex, resection after 2003 and resection at a large (vs. medium), urban, teaching high volume center (vs. low volume center) in the Northeast (vs. Midwest and South). Conclusions: Inpatient mortality and complications for gastrectomy and esophagectomy have improved over the past decade. Use of minimally invasive techniques is expanding with associated superior patient outcomes. Resection hospital characteristics drive which patients undergo laparoscopy for esophagus and stomach cancers.
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Affiliation(s)
- Lindsay A. Bliss
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Zeling Chau
- University of Massachusetts Medical School, Worcester, MA
| | - Catherine J. Yang
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | | | | | - Sing Chau Ng
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Arthur J. Moser
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jennifer F. Tseng
- Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
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Chau Z, Burish N, Curran T, Witkowski ER, Ng SC, Tseng JF. Insurance impacts readmission and costs for colorectal surgery. J Am Coll Surg 2013. [DOI: 10.1016/j.jamcollsurg.2013.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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14
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Ragulin-Coyne E, Witkowski ER, Chau Z, Chau S, Santry HP, Callery MP, Shah SA, Tseng JF. Is routine intraoperative cholangiogram necessary in the twenty-first century? A national view. J Gastrointest Surg 2013; 17:434-42. [PMID: 23292460 PMCID: PMC4570242 DOI: 10.1007/s11605-012-2119-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 12/03/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear. METHODS Nationwide Inpatient Sample 2004-2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost. RESULTS Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ∼25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p = 0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs. CONCLUSION Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons' routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes.
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Affiliation(s)
- Elizaveta Ragulin-Coyne
- Department of Surgery, Surgical Outcomes Analysis & Research (SOAR), University of Massachusetts Medical School, Room S3-752, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Elan R. Witkowski
- Department of Surgery, Surgical Outcomes Analysis & Research (SOAR), University of Massachusetts Medical School, Room S3-752, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Zeling Chau
- Department of Surgery, Surgical Outcomes Analysis & Research (SOAR), University of Massachusetts Medical School, Room S3-752, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Sing Chau
- Department of Surgery, Surgical Outcomes Analysis & Research (SOAR), University of Massachusetts Medical School, Room S3-752, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Heena P. Santry
- Department of Surgery, Surgical Outcomes Analysis & Research (SOAR), University of Massachusetts Medical School, Room S3-752, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Mark P. Callery
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Stoneman 9, Boston, MA 02215, USA
| | - Shimul A. Shah
- Department of Surgery, Surgical Outcomes Analysis & Research (SOAR), University of Massachusetts Medical School, Room S3-752, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Jennifer F. Tseng
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Stoneman 9, Boston, MA 02215, USA
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Abstract
Pancreatic cancer is an aggressive and highly lethal malignancy. Surgical resection is a modest tool, but it provides the only potential for curative therapy and often prolongs survival. This article reviews the progress made on both local and national levels towards an era of safer pancreatic surgery, while discussing both perioperative outcomes and long-term survival after resection.
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Affiliation(s)
- Elan R Witkowski
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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16
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Ragulin-Coyne E, Carroll JE, Smith JK, Witkowski ER, Ng SC, Shah SA, Zhou Z, Tseng JF. Perioperative mortality after pancreatectomy: A risk score to aid decision-making. Surgery 2012; 152:S120-7. [DOI: 10.1016/j.surg.2012.05.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 05/11/2012] [Indexed: 01/26/2023]
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McDade TP, Smith JK, Chau Z, Witkowski ER, West JK, Tseng JF. Inequal benefits from regionalization of cancer care: The pancreatic cancer surgery paradigm. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.4059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4059 Background: Regionalization has been proposed for high-level care, including multidisciplinary cancer treatment and complex procedures. Pancreatic resections can serve as a marker for both. Using Massachusetts Division of Health Care Finance and Policy (DHCFP) data, we investigated regionalization of surgery for pancreatic cancer (PCa), its potential effect on perioperative outcomes, and disparities in access to high-volume PCa surgery centers. Methods: Using MA DHCFP Hospital Inpatient Discharge Data, 2005-2009, 10,524 discharges for PCa were identified, of which 746 were associated with pancreatic resection. Discharges with missing or out-of-state residence were excluded (n=704). Using geodetic methods and ZIP codes, center-to-center distances were calculated between patient (pt) and treating hospital. Median ZIP income was estimated from 2009 census data. High volume hospitals (4 of 25 performing pancreatic resections in MA) were defined using Leapfrog Criteria (> 11 per year (87th percentile for MA). Chi-square and logistic regression analyses were performed using SAS software. Results: Median age was 65. Pts were predominantly White (87.2%), with median ZIP income of $54,677. Pts travelled in-state up to 112 miles (median 15.4), with the majority resected at high volume hospitals (76%). Median length of stay (LOS) was 8.0 days, with LOS>1 week associated with low volume hospitals (p=0.0002). Of 14 in-hospital deaths, 7 were at low volume hospitals (4.14% of 169 pts) compared to 7 at high volume hospitals (1.31% of 535 pts) (p=0.0214). Predictors of shorter travel distance were: Black race (OR 4.45 (95% CI 1.66-11.93)), operation at low volume hospital (OR 2.62 (95% CI 1.81-3.77), and increased age (per year) (OR 1.02 (95% CI 1.00-1.03), but not sex or median income. Conclusions: Using MA statewide discharge data, regionalization of pancreatic cancer surgery to high-volume, better-outcome centers is seen to be occurring. However, it is not uniform, and disparities exist between groups of cancer pts that do and do not travel for their care. In the current era of scrutiny on cost, quality, and access to cancer care, further study into predictors of pts receiving optimal care is warranted.
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Affiliation(s)
- Theodore P. McDade
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA
| | - Jillian K Smith
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA
| | - Zeling Chau
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA
| | - Elan R. Witkowski
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA
| | - James K. West
- Massachusetts Department of Public Health, Boston, MA
| | - Jennifer F. Tseng
- Department of Surgery, Division of Surgical Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Abstract
e14691 Background: Evidence from preclinical models suggests that metformin may have antitumor activity against pancreatic adenocarcinoma. The effect in humans has not been well-described. A recent single-institution retrospective analysis suggested improved survival in diabetic patients who had been exposed to metformin. The current study was designed to determine whether metformin was independently associated with improved pancreatic cancer (PC) survival when compared to non-metformin controls using newly available national pharmacy data from Medicare Part D. Methods: Patients with diagnosed with AJCC Stage II-IV PC during 2007 were identified in the SEER-Medicare linked database. Part D events for oral diabetic medications were identified from the date of diagnosis until death or 12/31/2008, and divided into metformin-containing or non-metformin. Patients who did not receive an oral medication for diabetes, lacked continuous Part D prescription drug coverage, underwent surgical resection, or survived less than 30 days were excluded. Patient characteristics were compared by chi-square and Wilcoxon. Overall survival was compared by Kaplan-Meier log rank. Results: From an initial cohort of 899 patients, 100 met inclusion criteria and received oral diabetic medication. Of these, 31 received metformin and 69 non-metformin. Patient characteristics were similar among the groups, including median age (76.6 vs. 76.2, p=0.75), race distribution, Charlson comorbidity score and disease stage (p>0.05 for each). There was no statistically significant difference in median survival between the two groups: 5.6 months for metformin vs. 6.1 for non-metformin, p=0.93. Conclusions: This study using national Medicare Part D prescription drug claims revealed no detectable survival benefit for unresectable pancreatic cancer patients who received metformin when compared to non-metformin oral hypoglycemics. Sufficient power to detect modest benefits, however, will require additional subjects, which we anticipate in the near future. Additional studies are warranted and ongoing to determine the effect of metformin on pancreatic cancer survival.
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Affiliation(s)
- Elan R. Witkowski
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA
| | - Elizaveta Ragulin-Coyne
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA
| | - Zeling Chau
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA
| | - Theodore P. McDade
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA
| | - Sing Chau Ng
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA
| | - Jennifer F. Tseng
- Department of Surgery, Division of Surgical Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Witkowski ER, Smith JK, Ragulin-Coyne E, Ng SC, Shah SA, Tseng JF. Is it worth looking? Abdominal imaging after pancreatic cancer resection: a national study. J Gastrointest Surg 2012; 16:121-8. [PMID: 21972054 DOI: 10.1007/s11605-011-1699-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 09/14/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Abdominal imaging is often performed after pancreatic cancer resection. We attempted to quantify the volume and estimate the cost of complex imaging after pancreatectomy nationwide, and to determine whether their frequent use confers benefit. METHODS Patients with pancreatic adenocarcinoma who underwent resection were identified in Surveillance, Epidemiology and End Results-Medicare (1991-2005). Claims for abdominal imaging ≤5 years after resection were analyzed. Patients receiving annual CT scans were identified. Univariate and multivariate analyses were performed. To assess frequency of annual CT scanning in patients with superior survival, the top decile was further analyzed. RESULTS Eleven thousand eight hundred fifty studies were performed on 2,217 patients. Ten thousand five hundred forty-two (89%) were CT scans. The median number of scans doubled from three in 1991 to six in 2005 (p < 0.0001). Among patients with sufficient survival to allow for analysis, 51.3% received annual CT scans, while only 32.4% of top-performing patients received annual scans. Univariate analysis of the 10% of patients with superior survival did not reveal any significant benefit associated with annual imaging. CONCLUSION Utilization of complex imaging after pancreatic cancer resection has increased substantially among Medicare beneficiaries, driven primarily by an increasing number of CT scans. Our study demonstrated no significant survival benefit among patients who received scans on a routine basis.
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Affiliation(s)
- Elan R Witkowski
- Department of Surgery, Surgical Outcomes Analysis and Research, University of Massachusetts Medical School, 55 Lake Avenue North, S3-752, Worcester, MA 01655-0002, USA
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Murphy MM, Witkowski ER, Ng SC, McDade TP, Hill JS, Larkin AC, Whalen GF, Litwin DE, Tseng JF. Trends in adrenalectomy: a recent national review. Surg Endosc 2010; 24:2518-26. [PMID: 20336320 DOI: 10.1007/s00464-010-0996-z] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 02/26/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Adrenalectomy remains the definitive therapy for most adrenal neoplasms. Introduced in the 1990s, laparoscopic adrenalectomy is reported to have lower associated morbidity and mortality. This study aimed to evaluate national adrenalectomy trends, including major postoperative complications and perioperative mortality. METHODS The Nationwide Inpatient Sample was queried to identify all adrenalectomies performed during 1998-2006. Univariate and multivariate logistic regression were performed, with adjustments for patient age, sex, comorbidities, indication, year of surgery, laparoscopy, hospital teaching status, and hospital volume. Annual incidence, major in-hospital postoperative complications, and in-hospital mortality were evaluated. RESULTS Using weighted national estimate, 40,363 patients with a mean age of 54 years were identified. Men made up 40% of these patients, and 77% of the patients were white. The majority of adrenalectomies (83%) were performed for benign disease. The annual volume of adrenalectomies increased from 3,241 in 1998 to 5,323 in 2006 (p < 0.0001, trend analysis). The overall in-hospital mortality was 1.1%, with no significant change. Advanced age (< 45 years as the referent; ≥ 65 years: adjusted odds ratio [AOR], 4.10; 95%; confidence Interval [CI], 1.66-10.10) and patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.33; 96% CI, 2.34-8.02) were independent predictors of in-hospital mortality. Indication, year, hospital teaching status, and hospital volume did not independently affect perioperative mortality. Major postoperative in-hospital complications occurred in 7.2% of the cohort, with a significant increasing trend (1998-2000 [5.9%] vs 2004-2006 [8.1%]; p < 0.0001, trend analysis). Patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.77; 95% CI, 3.71-6.14), recent year of surgery (1998-2000 as the referent; 2004-2006: AOR, 1.40; 95% CI, 1.09-1.78), and benign disease (malignant disease as the referent; benign disease: AOR, 1.98; 95% CI, 1.55-2.53) were predictive of major postoperative complications at multivariable analyses, whereas laparoscopy was protective (no laparoscopy as the referent; laparoscopy: AOR, 0.62; 95% CI, 0.47-0.82). CONCLUSION Adrenalectomy is increasingly performed nationwide for both benign and malignant indications. In this study, whereas perioperative mortality remained low, major postoperative complications increased significantly.
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Affiliation(s)
- Melissa M Murphy
- Department of Surgery, Surgical Outcomes Analysis and Research, University of Massachusetts Medical School, 55 Lake Avenue North, Suite S3-752, Worcester, MA 01655, USA.
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