Thomas A Aloia

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

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Publications (154)797.89 Total impact

  • Ryan W. Day · Thomas A. Aloia
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    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
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    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; 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
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    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; DOI:10.1111/hpb.12439 · 2.68 Impact Factor
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    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
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    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
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    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
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    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
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    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-1132. DOI:10.1016/S0016-5085(15)33861-0 · 16.72 Impact Factor
  • Gastroenterology 04/2015; 148(4):S-1161. DOI:10.1016/S0016-5085(15)33964-0 · 16.72 Impact Factor
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    ABSTRACT: Background: Gastric cardia cancer is currently treated with several operations. The purpose of the current study was to compare outcomes associated with three common operative approaches. Methods: The ACS-NSQIP Participant Use File was searched to identify all patients with gastric cardia malignancy who underwent total gastrectomy (TG), transhiatal esophagectomy (THE), or thoraco-abdominal esophagectomy (TAE) between 2005 and 2012. Demographic, perioperative risk factors, and outcomes were analyzed. Results: Overall, there were 982 patients identified in the database who met inclusion criteria. The median age was 65 years (range 20-88) and 807 (82.2 %) were male. The number of patients allocated to each approach was 204 TGs (20.8 %), 271 THE (27.6 %), and 507 TAE (51.6 %). All approaches had similar major morbidity, cardiopulmonary morbidity, and 30-day mortality, however, TAE was associated with the highest overall morbidity (TAE 49.9 % vs. TG 40.7 % and THE 43.5 %, p = 0.048). The independent risk factors predicting mortality were age greater than 65 years, history of myocardial infarction, and postoperative cardiopulmonary morbidity. Conclusions: For patients with proximal gastric cancer, the three most common operative approaches were associated with clinically-significant rates of overall and major morbidity. Approach-associated morbidity should be considered along with tumor location and extent when choosing a technique for resection of gastric cardia malignancy.
    Gastroenterology 04/2015; 148(4):S-1117. DOI:10.1016/S0016-5085(15)33810-5 · 16.72 Impact Factor
  • Gastroenterology 04/2015; 148(4):S-1132. DOI:10.1016/S0016-5085(15)33858-0 · 16.72 Impact Factor
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    ABSTRACT: To investigate prognostic impact of parenchymal-sparing hepatectomy (PSH) for solitary small colorectal liver metastasis (CLM). It is unclear whether PSH confers an oncologic benefit through increased salvageability or is a detriment through increasing recurrence rate. Database of 300 CLM patients with a solitary tumor (≤30 mm in size) was reviewed from 1993 to 2013. A total of 156 patients underwent PSH and 144 patients underwent right hepatectomy, left hepatectomy, or left lateral sectionectomy (non-PSH group). The rate of PSH increased over the study period (P < 0.01). PSH did not impact negatively on overall (OS), recurrence-free, and liver-only recurrence-free survival, compared with non-PSH (P = 0.53, P = 0.97, and P = 0.69, respectively). Liver-only recurrence was observed in 22 patients (14%) in the PSH and 25 (17%) in the non-PSH group (P = 0.44). Repeat hepatectomy was more frequently performed in the PSH group (68% vs 24%, P < 0.01). Subanalysis of patients with liver-only recurrence revealed better 5-year overall survival from initial hepatectomy and from liver recurrence in the PSH than in the non-PSH group [72.4% vs 47.2% (P = 0.047) and 73.6% vs 30.1% (P = 0.018), respectively]. Multivariate analysis revealed that non-PSH was a risk of noncandidacy for repeat hepatectomy (hazard ratio: 8.18, confidence interval: 1.89-45.7, P < 0.01). PSH did not increase recurrence in the liver remnant but more importantly improved 5-year survival in case of recurrence (salvageability). PSH should be the standard approach to CLM to allow for salvage surgery in case of liver recurrence.
    Annals of Surgery 03/2015; DOI:10.1097/SLA.0000000000001194 · 8.33 Impact Factor
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    ABSTRACT: Readmission rates of 9.7% to 15.5% after hepatectomy have been reported. These rates are difficult to interpret due to variability in the time interval used to monitor readmission. The aim of this study was to refine the definition of readmission after hepatectomy. A prospectively maintained database of 3,041 patients who underwent hepatectomy from 1998 through 2013 was merged with the hospital registry to identify readmissions. Area under the curve (AUC) analysis was used to determine the time interval that best captured unplanned readmission. Readmission rates at 30 days, 90 days, and 1 year after discharge were 10.7% (n = 326), 17.3% (n = 526), and 31.9% (n = 971) respectively. The time interval that best accounted for unplanned readmissions was 45 days after discharge (AUC, 0.956; p < 0.001), during which 389 patients (12.8%) were readmitted (unplanned: n = 312 [10.3%]; planned: n = 77 [2.5%]). In comparison, the 30 days after surgery interval (used in the ACS-NSQIP database) omitted 65 (26.3%) unplanned readmissions. Multivariate analysis revealed the following risk factors for unplanned readmission: diabetes (odds ratio [OR] 1.6; p = 0.024), right hepatectomy (OR 2.1; p = 0.034), bile duct resection (OR 1.9; p = 0.034), abdominal complication (OR 1.8; p = 0.010), and a major postoperative complication (OR 2.4; p < 0.001). Neither index hospitalization > 7 days nor postoperative hepatobiliary complications were independently associated with readmission. To accurately assess readmission after hepatectomy, patients should be monitored 45 days after discharge. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Surgeons 02/2015; 221(1). DOI:10.1016/j.jamcollsurg.2015.01.063 · 5.12 Impact Factor
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    ABSTRACT: The rate of adverse events after pancreatectomy is widely reported as a measure of surgical quality. However, morbidity data are routinely acquired retrospectively and often are reported at 30 days. The authors hypothesized that morbidity after pancreatectomy is therefore underreported. They sought to compare rates of adverse events calculated at multiple time points after pancreatectomy. The authors instituted an active surveillance system to detect, categorize, and grade the severity of all adverse events after pancreatectomy, using the modified Accordion system and International Study Group of Pancreatic Surgery definitions. All patients and clinical events were monitored directly for at least 90 days after surgery. Of 315 consecutively monitored patients, 239 (76 %) experienced 500 unique adverse events. The absolute number of unique adverse events increased by 32 % between index discharge and 90 days and by 10 % between 30 and 90 days. The number of severe adverse events increased by 96 % between discharge and 90 days and by 29 % between 30 and 90 days. In this study, 16 % of the patients experienced at least one severe adverse event within the index hospitalization, 24 % within 30 postoperative days, and 29 % within 90 days. Among the 80 readmissions that occurred within 90 days, 28 (35 %) occurred later than 30 days after pancreatectomy. Approximately one-third of severe adverse events and readmissions are reported more than 30 days after surgery. All adverse events that occur within 90 days of surgery must be identified and reported for accurate characterization of the morbidity associated with pancreatectomy.
    Annals of Surgical Oncology 02/2015; 22(11). DOI:10.1245/s10434-015-4437-z · 3.93 Impact Factor
  • T.A. Aloia
    European Journal of Surgical Oncology 02/2015; 41(5). DOI:10.1016/j.ejso.2015.02.001 · 3.01 Impact Factor

Publication Stats

3k Citations
797.89 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
  • 2007–2009
    • Baylor College of Medicine
      • • Department of Surgery
      • • Department of Medicine
      Houston, TX, 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