Thomas A Aloia

University of Texas MD Anderson Cancer Center, Houston, Texas, United States

Are you Thomas A Aloia?

Claim your profile

Publications (161)839.89 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Perioperative blood transfusions suppress immunity and increase hospital costs. Despite multiple improvements in perioperative care, rates of transfusion during/after hepatectomy are reported to range from 25 to 50%. The purpose of this study was to determine the current risk factors for perihepatectomy transfusion by assessing the impact of recent technical advances in liver surgery on transfusion rates. Methods: Using our prospectively maintained hepatobiliary tumor database from a high-volume center, a modern cohort of 2,249 hepatectomies (2004-2013) were identified. Patient and operative characteristics were compared between 2 time periods, 2004-2008 (n = 1,139) and 2009-2013 (n = 1,110). Throughout the study interval, transfusions were given based on clinical assessment and not triggered by laboratory thresholds. Results: Compared with the early cohort, the recent cohort had more patients with an American Society of Anesthesiologists score of ≥3 (79 vs 74%), preoperative chemotherapy (73 vs 68%), and a lesser median preoperative hemoglobin (12.9 vs 13.1 mg/dL) and platelet (215,000 vs 243,000) values (all P < .001). Despite these adverse risk factors, with an increasing use of the 2-surgeon resection technique (63 vs 50%), estimated blood loss (309 vs 394 mL), transfusion rates (6 vs 15%), and duration of stay (7.0 vs 8.4 days) were decreased (all P < .001) with no change in overall morbidity or mortality. Multivariate analysis of the recent cohort determined that the independent risk factors associated with transfusion were preoperative anemia and >350 mL of blood loss. The only independent factor associated with less transfusion was use of the 2-surgeon technique for hepatic parenchymal transection. Conclusion: With the exception of patients with moderate to severe preoperative anemia requiring major hepatectomy, recent technical advances have decreased significantly the need for transfusion in liver surgery.
    Surgery 11/2015; DOI:10.1016/j.surg.2015.10.006 · 3.38 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: Previous studies have suggested that the use of regional anesthesia can reduce recurrence risk after oncologic surgery. The purpose of this study was to assess the effect of epidural anesthesia on recurrence-free (RFS) and overall survival (OS) after hepatic resection for colorectal liver metastases (CLM). Methods: After approval of the institutional review board, the records of all adult patients who underwent elective hepatic resection between January 2006 and October 2011 were retrospectively reviewed. Patients were categorized according to use of perioperative epidural analgesia versus intravenous analgesia. Univariate and multivariate analyses were performed to identify factors influencing RFS and OS. Results: Of 510 total patients, 390 received epidural analgesia (EA group) and 120 patients received intravenous analgesia (IVA group). Compared with the IVA group, more patients in the EA group underwent associated surgical procedures with consequently longer operative times (p < 0.001). In addition, the EA group received more intraoperative fluids and had higher urine output volumes (p ≤ 0.001). Five-year RFS was longer in the EA group (34.7 %) compared with the IVA group (21.1 %). On multivariate analysis, the receipt of epidural analgesia was an independent predictor of improved RFS (p = 0.036, hazard ratio [HR] 0.74; 95 % confidence interval [CI] 0.56-0.95), but not OS (p = 0.102, HR 0.72; 95 % CI 0.49-1.07). Conclusions: This study suggests an association between epidural analgesia and improved RFS, but not OS, after CLM resection. These results warrant further prospective, randomized studies on the benefits of regional anesthesia on oncologic outcomes after hepatic resection for CLM.
    Annals of Surgical Oncology 10/2015; DOI:10.1245/s10434-015-4933-1 · 3.93 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose: Standard therapies for localized inoperable intrahepatic cholangiocarcinoma (IHCC) are ineffective. Advances in radiotherapy (RT) techniques and image guidance have enabled ablative doses to be delivered to large liver tumors. This study evaluated the effects of RT dose escalation in the treatment of IHCC. Patients and methods: Seventy-nine consecutive patients with inoperable IHCC were identified and treated with definitive RT from 2002 to 2014. At diagnosis, the median tumor size was 7.9 cm (range, 2.2 to 17 cm). Seventy patients (89%) received systemic chemotherapy before RT. RT doses were 35 to 100 Gy (median, 58.05 Gy) in three to 30 fractions for a median biologic equivalent dose (BED) of 80.5 Gy (range, 43.75 to 180 Gy). Results: Median follow-up time for patients alive at time of analysis was 33 months (range, 11 to 93 months). Median overall survival (OS) time after diagnosis was 30 months; 3-year OS rate was 44%. Radiation dose was the single most important prognostic factor; higher doses correlated with an improved local control (LC) rate and OS. The 3-year OS rate for patients receiving BED greater than 80.5 Gy was 73% versus 38% for those receiving lower doses (P = .017); 3-year LC rate was significantly higher (78%) after a BED greater than 80.5 Gy than after lower doses (45%, P = .04). BED as a continuous variable significantly affected LC (P = .009) and OS (P = .004). There were no significant treatment-related toxicities. Conclusion: Delivery of higher doses of RT improves LC and OS in inoperable IHCC. A BED greater than 80.5 Gy seems to be an ablative dose of RT for large IHCCs, with long-term survival rates that compare favorably with resection.
    Journal of Clinical Oncology 10/2015; 93(3). DOI:10.1200/JCO.2015.61.3778 · 18.43 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Previous studies by different authors have reported their readmission rates after pancreatectomy as either "30 days from discharge" or "90 days from surgery." The objective of this study was to determine which of these definitions captures the most surgery-related complications. Methods: A prospectively maintained database at a high volume center was queried to identify all individuals who underwent pancreatectomy between 2000 and 2012 for any diagnosis. The data was analyzed at 30 days after discharge and 90 days after operation. The optimal timing for complication reporting was defined as the time point that maximized the capture of surgery-related readmissions and direct major surgical complications while minimizing the capture of disease (cancer)-related readmissions. Results: There were 1123 patients included during the study time period. The median age was 63 years old, and 55.6 % were male. Operations included 833 (74.2 %) pancreaticoduodenectomies, 257 (22.9 %) distal pancreatectomies, 18 (1.6 %) total pancreatectomies, and 15 (1.3 %) central pancreatectomies. Surgery-related readmissions occurred in 248 (22 %) individuals, while readmission related to malignant disease progression occurred in 25 (2 %) individuals. The 30 days from discharge definition captured 184 surgery-related readmissions and 1 disease-related readmission (sensitivity 0.74, specificity 0.96). The 90 days from surgery definition captured 215 surgery-related readmissions and 1 disease-related readmission (sensitivity 0.87, specificity 0.96). Major surgical complication was the only independent factor associated with readmission not captured by the 30 days from discharge definition (p = 0.002, HR 3.94, 95 % CI 1.44-12.22). Conclusion: The 90 days from surgery definition was superior to the 30 days from discharge definition, especially with regards to readmission related to major surgical complications.
    Journal of Gastrointestinal Surgery 10/2015; DOI:10.1007/s11605-015-2984-z · 2.80 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: At a recently concluded Americas Hepato-Pancreato-Biliary Association Annual Meeting, a Clinical Practice Guidelines Conference Series was convened with the topic focusing on Venous Thromboembolism (VTE) Prophylaxis in Liver Surgery. The symposium brought together hepatobiliary surgeons from three continents as well as medical experts in hematology and coagulation. Methods: The content of the discussion included literature reviews, evaluation of multi-institutional VTE outcome data, and examination of practice patterns at multiple high-volume centers. Results: Literature review demonstrated that, within gastrointestinal surgery, liver resection patients are at particularly high-risk for VTE. Recent evidence clearly indicates a direct relationship between the magnitude of hepatectomy and postoperative VTE rates, however, the PT/INR does not accurately reflect the coagulation status of the post-hepatectomy patient. Evaluation of available data and practice patterns regarding the utilization and timing of anticoagulant VTE prophylaxis led to recommendations regarding preoperative and postoperative thromboprophylaxis for liver surgery patients. Conclusions: This conference was effective in consolidating our knowledge of coagulation abnormalities after liver resection. Based on the expert review of the available data and practice patterns, a number of recommendations were developed.
    Journal of Gastrointestinal Surgery 10/2015; DOI:10.1007/s11605-015-2902-4 · 2.80 Impact Factor

  • Journal of the American College of Surgeons 10/2015; DOI:10.1016/j.jamcollsurg.2015.09.011 · 5.12 Impact Factor
  • R W Day · S Fielder · J Calhoun · H Kehlet · V Gottumukkala · T A Aloia ·
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Enhanced recovery (ER) protocols are used widely in surgical practice. As protocols are multidisciplinary with multiple components, it is difficult to compare and contrast reports. The present study examined compliance and transferability to clinical practice among ER publications related to colorectal surgery. Methods: PubMed, Embase and Cochrane Central Register databases were searched for current colorectal ER manuscripts. Each publication was assessed for the number of ER elements, whether the element was explained sufficiently so that it could be transferred to clinical practice, and compliance with the ER element. Results: Some 50 publications met the reporting criteria for inclusion. A total of 22 ER elements were described. The median number of elements included in each publication was 9, and the median number of included patients was 130. The elements most commonly included in ER pathways were early postoperative diet advancement (49, 98 per cent) and early mobilization (47, 94 per cent). Early diet advancement was sufficiently explained in 43 (86 per cent) of the 50 publications, but only 22 (45 per cent) of 49 listing the variable reported compliance. The explanation for early mobilization was satisfactory in 41 (82 per cent) of the 50 publications, although only 14 (30 per cent) of 47 listing the variable reported compliance. Other ER elements had similar rates of explanation and compliance. The most frequently analysed outcome measures were morbidity (49, 98 per cent), length of stay (47, 94 per cent) and mortality (45, 90 per cent). Conclusion: The current standard of reporting is frequently incomplete. To transfer knowledge and facilitate implementation of pathways that demonstrate improvements in perioperative care and recovery, a consistent structured reporting platform is needed.
    British Journal of Surgery 09/2015; DOI:10.1002/bjs.9918 · 5.54 Impact Factor
  • Ryan W. Day · Thomas A. Aloia ·
    [Show abstract] [Hide abstract]
    ABSTRACT: Patients with resectable cancers present unique challenges to surgical and anesthetic teams. These patients frequently require invasive and lengthy procedures that incur higher levels of disability. At the same time, the pressure to return cancer surgery patients to adjuvant cancer therapies places an additional responsibility on care teams. To meet this need, many cancer centers are utilizing enhanced recovery pathways of care. Although many of the practices contained within these pathways have been vetted in non-oncologic and minimally invasive oncologic procedures, major oncologic surgery poses unique challenges to their implementation. The purpose of this review is to highlight the challenges and opportunities that enhanced recovery protocols bring to oncologic surgery. Additionally, special considerations for the measurement of recovery in cancer patients are discussed.
    09/2015; 5(3). DOI:10.1007/s40140-015-0115-8
  • Marah N. Short · Vivian Ho · Thomas A. Aloia ·
    [Show abstract] [Hide abstract]
    ABSTRACT: Background and Objectives Health care providers add multiple processes to the care of complex cancer patients, believing they prevent and/or ameliorate complications. However, the relationship between these processes, complication remediation, and expenditures is unknown.Methods Data for patients with cancer diagnoses undergoing colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection were obtained from hospital and inpatient physician Medicare claims for the years 2005–2009. Risk-adjusted regression analyses measured the association between hospitalization costs and processes presumed to prevent and/or remedy complications common to high-risk procedures.ResultsAfter controlling for comorbidities, analysis identified associations between increased costs and use of multiple processes, including arterial lines (4–12% higher; P < 0.001) and pulmonary artery catheters (23–33% higher; P < 0.001). Epidural analgesia was not associated with higher costs. Consultations were associated with 24-44% (P < 0.001) higher costs, and total parenteral nutrition was associated with 13–31% higher costs (P < 0.001).Conclusions Many frequently utilized processes and services presumed to avoid and/or ameliorate complications are associated with increased surgical oncology costs. This suggests that the patient-centered value of each process should be measured on a procedure-specific basis. Likewise, further attention should be focused on defining the efficacy of each of these costly, but frequently unproven, additions to perioperative care. J. Surg. Oncol. © 2015 Wiley Periodicals, Inc.
    Journal of Surgical Oncology 09/2015; 112(6). DOI:10.1002/jso.24053 · 3.24 Impact Factor
  • Thomas A Aloia ·

    JAMA SURGERY 08/2015; DOI:10.1001/jamasurg.2015.1646 · 3.94 Impact Factor
  • Ryan W Day · Claudius Conrad · Jean-Nicolas Vauthey · Thomas A Aloia ·
    [Show abstract] [Hide abstract]
    ABSTRACT: Various techniques, including portal vein embolization (PVE), contralateral portal vein ligation (PVL) and associating liver partition and portal vein ligation (ALPPS), are being used to augment the future liver remnant (FLR) volume in preparation for a major hepatectomy. The present study aims to survey and document the availability, variation, utilization and attitudes toward these techniques across centres in North and South America. A descriptive, 20-question survey was developed and internally validated with expert review. The survey was distributed to 115 centres in North and South America. Of the 115 centres, 54 institutions (47%) returned the surveys. Regarding the question of which modality was most likely to produce adequate hypertrophy, the respondents were equally distributed (ALPPS, 37%; PVE, 35%; equal, 22%). The procedure that respondents judged the safest to achieve liver hypertrophy was PVE (82%). Institutions with capability to extended PVE to segment IV rated the likelihood of PVE technical success (6.2 versus 8.5, P = 0.012) and likelihood of subsequent hypertrophy (5.6 versus 7.8, P = 0.011) higher than institutions without this capability. Although the use of modern embolic materials was associated with a likelihood of successful PVE (P = 0.032), only 49% of respondents who performed PVE used embolic microspheres. There exists significant variability in utilization of and attitudes towards the available techniques for FLR volume augmentation. Penetration of best practice techniques for PVE is lacking, and may be contributing towards disappointment with PVE efficacy, potentially motivating the utilization of the riskier ALPPS procedure. © 2015 International Hepato-Pancreato-Biliary Association.
    HPB 08/2015; 17(10). DOI:10.1111/hpb.12439 · 2.68 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: An American Hepato-Pancreato-Biliary Association (AHPBA)-sponsored consensus meeting of expert panellists was convened on 15 January 2014 to review current evidence on the management of gallbladder carcinoma in order to establish practice guidelines. In summary, within high incidence areas, the assessment of routine gallbladder specimens should include the microscopic evaluation of a minimum of three sections and the cystic duct margin; specimens with dysplasia or proven cancer should be extensively sampled. Provided the patient is medically fit for surgery, data support the resection of all gallbladder polyps of >1.0 cm in diameter and those with imaging evidence of vascular stalks. The minimum staging evaluation of patients with suspected or proven gallbladder cancer includes contrasted cross-sectional imaging and diagnostic laparoscopy. Adequate lymphadenectomy includes assessment of any suspicious regional nodes, evaluation of the aortocaval nodal basin, and a goal recovery of at least six nodes. Patients with confirmed metastases to N2 nodal stations do not benefit from radical resection and should receive systemic and/or palliative treatments. Primary resection of patients with early T-stage (T1b-2) disease should include en bloc resection of adjacent liver parenchyma. Patients with T1b, T2 or T3 disease that is incidentally identified in a cholecystectomy specimen should undergo re-resection unless this is contraindicated by advanced disease or poor performance status. Re-resection should include complete portal lymphadenectomy and bile duct resection only when needed to achieve a negative margin (R0) resection. Patients with preoperatively staged T3 or T4 N1 disease should be considered for clinical trials of neoadjuvant chemotherapy. Following R0 resection of T2-4 disease in N1 gallbladder cancer, patients should be considered for adjuvant systemic chemotherapy and/or chemoradiotherapy. © 2015 International Hepato-Pancreato-Biliary Association.
    HPB 08/2015; 17(8):681-90. DOI:10.1111/hpb.12444 · 2.68 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: An American Hepato-Pancreato-Biliary Association (AHPBA)-sponsored consensus meeting of expert panellists met on 15 January 2014 to review current evidence on the management of hilar cholangiocarcinoma in order to establish practice guidelines and to agree consensus statements. It was established that the treatment of patients with hilar cholangiocarcinoma requires a coordinated, multidisciplinary approach to optimize the chances for both durable survival and effective palliation. An adequate diagnostic and staging work-up includes high-quality cross-sectional imaging; however, pathologic confirmation is not required prior to resection or initiation of a liver transplant trimodal treatment protocol. The ideal treatment for suitable patients with resectable hilar malignancy is resection of the intra- and extrahepatic bile ducts, as well as resection of the involved ipsilateral liver. Preoperative biliary drainage is best achieved with percutaneous transhepatic approaches and may be indicated for patients with cholangitis, malnutrition or hepatic insufficiency. Portal vein embolization is a safe and effective strategy for increasing the future liver remnant (FLR) and is particularly useful for patients with an FLR of <30%. Selected patients with unresectable hilar cholangiocarcinoma should be evaluated for a standard trimodal protocol incorporating external beam and endoluminal radiation therapy, systemic chemotherapy and liver transplantation. Post-resection chemoradiation should be offered to patients who show high-risk features on surgical pathology. Chemoradiation is also recommended for patients with locally advanced, unresectable hilar cancers. For patients with locally recurrent or metastatic hilar cholangiocarcinoma, first-line chemotherapy with gemcitabine and cisplatin is recommended based on multiple Phase II trials and a large randomized controlled trial including a heterogeneous population of patients with biliary cancers.
    HPB 08/2015; 17(8):691-9. DOI:10.1111/hpb.12450 · 2.68 Impact Factor
  • K W Brudvik · S E Kopetz · L Li · C Conrad · T A Aloia · J-N Vauthey ·
    [Show abstract] [Hide abstract]
    ABSTRACT: In patients with advanced colorectal cancer, KRAS mutation status predicts response to treatment with monoclonal antibody targeting the epithelial growth factor receptor (EGFR). Recent reports have provided evidence that KRAS mutation status has prognostic value in patients with resectable colorectal liver metastases (CLM) irrespective of treatment with chemotherapy or anti-EGFR therapy. A meta-analysis was undertaken to clarify the impact of KRAS mutation on outcomes in patients with resectable CLM. PubMed, Embase and Cochrane Library databases were searched systematically to identify full-text articles reporting KRAS-stratified overall (OS) or recurrence-free (RFS) survival after resection of CLM. Hazard ratios (HRs) and 95 per cent c.i. from multivariable analyses were pooled in meta-analyses, and a random-effects model was used to calculate weight and overall results. The search returned 355 articles, of which 14, including 1809 patients, met the inclusion criteria. Eight studies reported OS after resection of CLM in 1181 patients. The mutation rate was 27·6 per cent, and KRAS mutation was negatively associated with OS (HR 2·24, 95 per cent c.i. 1·76 to 2·85). Seven studies reported RFS after resection of CLM in 906 patients. The mutation rate was 28·0 per cent, and KRAS mutation was negatively associated with RFS (HR 1·89, 1·54 to 2·32). KRAS mutation status is a prognostic factor in patients undergoing resection of colorectal liver metastases and should be considered in the evaluation of patients having liver resection. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.
    British Journal of Surgery 07/2015; 102(10). DOI:10.1002/bjs.9870 · 5.54 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Although simulation training and evaluation have become increasingly popular for teaching minimally invasive surgery, tools to measure open surgical skills remain underdeveloped. As there is increasing demand for objective measures of technical competency at the completion of surgical training (postgraduate year [PGY]-6 and -7), this project was designed to assess the feasibility, reliability, and validity of a novel open surgical skills evaluation tool, the 8-min suture test (8MST). During an annual surgical skills laboratory session, fellows and residents were asked to complete a simulated end-to-end vascular anastomosis. They were limited to 8 min to perform the anastomosis between two 12-mm Dacron grafts mounted on a customized platform. Their real-time and video-recorded performance was scored by two blinded evaluators and compared with their faculty-rated technical performance on clinical rotations completed around the time of 8MST administration. PGY-6 and PGY-7 trainees were compared across several domains including 8MST total score (4.6 versus 5.5, P = 0.030), 8MST setup score (2.3 versus 2.4, P = 0.797), 8MST technical score (2.3 versus 3.1, P = 0.026), and clinical performance score (3.1 versus 3.6, P = 0.006). Comparison of 8MST total score to the clinical performance score identified a strong relationship with a Pearson r = 0.55 (P < 0.001) and r(2) = 0.30. Additionally, 8MST displayed high inter-rater reliability and test-retest reliability. The 8MST is a rapid, feasible, inexpensive, reliable, and valid test for assessment of surgical trainee technical abilities. Copyright © 2015 Elsevier Inc. All rights reserved.
    Journal of Surgical Research 06/2015; DOI:10.1016/j.jss.2015.06.057 · 1.94 Impact Factor

  • Gynecologic Oncology 06/2015; 137(3):595. DOI:10.1016/j.ygyno.2015.03.029 · 3.77 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: We investigated outcomes by primary tumor type in patients who underwent resection of liver metastases from gastrointestinal stromal tumors (GIST), leiomyosarcomas, and other sarcomas. Our institutional liver database was used to identify patients who underwent resection from 1998 through 2013. Histopathological, clinical, and survival data were analyzed. One hundred forty-six patients underwent resection of liver metastases from GIST (n = 49), leiomyosarcomas (n = 47), or other sarcomas (n = 50). The 5-year overall survival (OS) rates in patients with GIST, leiomyosarcomas, and other sarcomas were 55.3, 48.4, and 44.9 %, respectively, and the 10-year OS rates were 52.5, 9.2, and 23.0 %, respectively. The 5-year recurrence-free survival (RFS) rate was better for GIST (35.7 %; p = 0.003) than for leiomyosarcomas (3.4 %) and other sarcomas (21.4 %). Lung recurrence was more common for leiomyosarcomas (36 % of patients; p < 0.0001) than for other sarcomas (12 %) and GIST (2 %). For GIST, the findings support a benefit of imatinib regarding the 5-year RFS rate compared to resection alone (47.1 vs. 9.5 %; p = 0.013). For leiomyosarcoma, primary tumor location did not affect the 5-year RFS rate (intraabdominal 14.5 %; other location 0 %; p = 0.182). Liver metastases from GIST, leiomyosarcomas, and other sarcomas should be assessed separately as their survival and recurrence patterns are different. This is especially important for GIST, for which imatinib is now available.
    Journal of Gastrointestinal Surgery 05/2015; 19(8). DOI:10.1007/s11605-015-2845-9 · 2.80 Impact Factor

  • Gastroenterology 04/2015; 148(4):S-1106-S-1107. DOI:10.1016/S0016-5085(15)33769-0 · 16.72 Impact Factor

  • Gastroenterology 04/2015; 148(4):S-1104. DOI:10.1016/S0016-5085(15)33761-6 · 16.72 Impact Factor

  • Gastroenterology 04/2015; 148(4):S-1161. DOI:10.1016/S0016-5085(15)33964-0 · 16.72 Impact Factor

Publication Stats

3k Citations
839.89 Total Impact Points


  • 2005-2015
    • University of Texas MD Anderson Cancer Center
      • • Department of Surgical Oncology
      • • Department of Surgery
      Houston, Texas, United States
    • Duke University
      • Department of Surgery
      Durham, North Carolina, United States
  • 2014
    • University of Houston
      Houston, Texas, United States
  • 2012
    • Fox Chase Cancer Center
      Filadelfia, Pennsylvania, United States
  • 2008-2010
    • Weill Cornell Medical College
      • Department of Surgery
      New York, New York, United States
    • Houston Methodist Hospital
      Houston, Texas, United States
    • University Medical Center Utrecht
      Utrecht, Utrecht, Netherlands
  • 2007-2008
    • Baylor College of Medicine
      • • Department of Medicine
      • • Department of Surgery
      Houston, Texas, United States
    • Université Paris-Sud 11
      • Faculty of Medicine
      Orsay, Île-de-France, France
  • 2003
    • Duke University Medical Center
      • Department of Surgery
      Durham, North Carolina, United States