Thomas A Aloia

University of Houston, Houston, Texas, United States

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Publications (134)574.81 Total impact

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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.
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    ABSTRACT: Readmission rates of 9.7%-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.
    Journal of the American College of Surgeons 02/2015; DOI:10.1016/j.jamcollsurg.2015.01.063 · 4.45 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; DOI:10.1245/s10434-015-4437-z · 3.94 Impact Factor
  • T.A. Aloia
    European Journal of Surgical Oncology 02/2015; 41(5). DOI:10.1016/j.ejso.2015.02.001 · 2.89 Impact Factor
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    ABSTRACT: To evaluate the patterns of (18)F-FDG uptake at the surgical margin after hepatectomy to identify features that may differentiate benign and malignant uptake. Patients who had undergone a PET/CT after hepatectomy were identified. Delay between resection and PET/CT, presence of uptake at the surgical margin, pattern of uptake, and maximal standardized value were recorded. The PET/CT findings were correlated with contrast-enhanced CT or MRI. There were 26 patients with increased 18F-FDG uptake; uptake was diffuse in seven and focal in 19. Diffuse uptake was due to inflammation in all cases. Focal uptake was due to recurrence in 12 and inflammation in seven cases. Defining a focal pattern only as a positive for malignancy yielded 100 % sensitivity, 87 % specificity, 37 % false positive rate. As expected, SUVmax was significantly higher for recurrence than inflammation, but did overlap. Contrast-enhanced CT allowed differentiation between malignant and benign uptake in all cases. F-FDG uptake after hepatectomy does not equate to recurrence and yields a high false positive rate. Diffuse uptake did not require additional evaluation in our sample. Focal uptake, however, may be due to recurrence; differentiating benign and malignant nodular uptake relies on optimal contrast-enhanced CT or MRI. • Marginal uptake exposes patients to the risk of false positive diagnosis of recurrence. • Benign and malignant patterns of marginal uptake overlap. • Diffuse marginal uptake in our experience, has a high chance to be inflammatory. • Focal marginal uptake can be due to recurrent tumour or inflammation. • Contrast-enhanced CT or MR allows the differentiation between benign and malignant uptake.
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    ABSTRACT: To investigate the legitimacy of 90-day mortality as a measure of hepatopancreatobiliary quality. The 90-day mortality rate has been increasingly but not universally reported after hepatopancreatobiliary surgery. The legitimacy of this definition as a measure of surgical quality has not been evaluated. We retrospectively reviewed the causes of all deaths that occurred within 365 postoperative days in patients undergoing hepatectomy (n = 2811) and/or pancreatectomy (n = 1092) from January 1997 to December 2012. The rates of surgery-related, disease-related, and overall mortality within 30 days, within 30 days or during the index hospitalization, within 90 days, and within 180 days after surgery were calculated. Seventy-nine (3%) surgery-related deaths and 92 (3%) disease-related deaths occurred within 365 days after hepatectomy. Twenty (2%) surgery-related deaths and 112 (10%) disease-related deaths occurred within 365 days after pancreatectomy. The overall mortality rates at 99 and 118 days optimally reflected surgery-related mortality after hepatobiliary and pancreatic operations, respectively. The 90-day overall mortality rate was a less sensitive but equivalently specific measure of surgery-related death. The 99- and 118-day definitions of postoperative mortality optimally reflected surgery-related mortality after hepatobiliary and pancreatic operations, respectively. However, among commonly reported metrics, the 90-day overall mortality rate represents a legitimate measure of surgical quality.
    Annals of Surgery 01/2015; DOI:10.1097/SLA.0000000000001048 · 7.19 Impact Factor
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    ABSTRACT: Background Little is known about changes in body composition that may occur during neoadjuvant therapy for pancreatic cancer. This study was designed to characterize these changes and their potential relationships with therapeutic outcomes. Methods The study population consisted of patients with potentially resectable pancreatic cancer treated on a phase II trial of neoadjuvant chemotherapy and chemoradiation. Skeletal muscle and adipose tissue compartments were measured before and after administration of neoadjuvant therapy using SliceOMatic software (TomoVision, 2012) and protocol-mandated CT scans. Sarcopenia was defined using gender-adjusted norms. Results Among 89 eligible patients, 46 (52 %) patients met anthropometric criteria for sarcopenia prior to the initiation of neoadjuvant therapy. Further depletion of skeletal muscle, visceral adipose tissue, and subcutaneous adipose tissue occurred during neoadjuvant therapy, but these losses did not preclude the performance of potentially curative surgery. Degree of skeletal muscle loss correlated with disease-free survival while visceral adipose loss was associated with overall and progression-free survival. However, completion of all therapy, including pancreatectomy, was the only independently significant predictor of outcome in a multivariate analysis of overall survival. Discussion These data suggest that body composition analysis of standard CT images may provide clinically relevant information for patients with potentially resectable pancreatic cancer who receive neoadjuvant therapy. Anthropometric changes must be considered in the design of preoperative therapy regimens, and further efforts should focus on maintenance of muscle and visceral adipose tissue in the preoperative setting.
    Annals of Surgical Oncology 12/2014; DOI:10.1245/s10434-014-4285-2 · 3.94 Impact Factor
  • Journal of the American College of Surgeons 11/2014; DOI:10.1016/j.jamcollsurg.2014.09.007 · 4.45 Impact Factor
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    ABSTRACT: Objective. To use a large-scale multi-institutional dataset to quantify the prevalence of packed red blood cell transfusions and examine the associations between transfusion and perioperative outcomes in gynecologic cancer surgery. Methods. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) participant use file was queried for all gynecologic cancer cases between 2010 and 2012. Demographic, preoperative and intraoperative variables were compared between transfusion and non-transfusion groups using chi-squared, Fisher's exact and Wilcoxon rank-sum tests. The primary endpoint was 30-day composite morbidity. Secondary endpoints included composite surgical site infections, mortality and length of stay. Results. A total of 8519 patients were analyzed, and 13.8% received a packed red blood cell transfusion. In the multivariate analysis, after adjusting for key clinical and perioperative factors, including preoperative anemia and case magnitude, transfusion was associated with higher composite morbidity (OR = 1.85, 95% CI 1.5-224), surgical site infections (OR 1.80,95% CI 139-2.35), mortality (OR 338, 95% Cl 1.80-636) and length of hospital stay (3.02 days v. 7.17 days, P < 0.001). Conclusions. Blood transfusions are associated with increased surgical wound infections, composite morbidity and mortality. Based on our analysis of the NSQIP database, transfusion practices in gynecologic cancer should be scrutinized. Examination of institutional practices and creation of transfusion guidelines for gynecologic malignancies could potentially result in better utilization of blood bank resources and clinical outcomes among patients.
    Gynecologic Oncology 11/2014; 136(1). DOI:10.1016/j.ygyno.2014.11.009 · 3.69 Impact Factor
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    ABSTRACT: Background Advances in multidisciplinary care are changing the prognostic impact of colorectal lung metastases. Resection of colorectal liver metastases (CLM) may benefit patients with synchronous lung metastases even when lung metastases are not resected. The aim of this study was to investigate the survival of patients undergoing complete resection of CLM in the setting of unresected lung metastases. Patients and Methods We compared survival among 98 patients who underwent resection of CLM with unresected lung metastases, 64 who received only chemotherapy for limited colorectal liver and lung metastases, and 41 who underwent resection of both liver and lung metastases. Prognostic factors were investigated in the patients who underwent resection of CLM only. Results The 3-year/5-year overall survival (OS) rates of patients with CLM resection only (42.9 %/13.1 %) were better than those of patients treated with chemotherapy only (14.1 %/1.6 %; p p KRAS mutation [hazard ratio (HR) 2.10; 95 % confidence interval (CI) 1.21–3.64; p p = 0.04) were independent predictors of worse OS. Survival of patients without these risk factors was similar to that of patients with curative metastasectomy. Conclusions Complete resection of metastases remains the primary goal of treatment for stage IV colorectal cancer. Resection of CLM without resection of lung metastases is associated with an intermediate survival between that of patients treated with palliative and curative intent and should be considered in selected patients.
    Annals of Surgical Oncology 11/2014; 22(5). DOI:10.1245/s10434-014-4207-3 · 3.94 Impact Factor
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    ABSTRACT: Background RAS mutations have been reported to be a potential prognostic factor in patients with colorectal liver metastases (CLM). However, the impact of RAS mutations on response to chemotherapy remains unclear. The purpose of this study was to investigate the correlation between RAS mutations and response to preoperative chemotherapy and their impact on survival in patients undergoing curative resection of CLM. Methods RAS mutational status was assessed and its relation to morphologic response and pathologic response was investigated in 184 patients meeting inclusion criteria. Predictors of survival were assessed. The prognostic impact of RAS mutational status was then analyzed using two different multivariate models, including either radiologic morphologic response (model 1) or pathologic response (model 2). Results Optimal morphologic response and major pathologic response were more common in patients with wild-type RAS (32.9 and 58.9 %, respectively) than in patients with RAS mutations (10.5 and 36.8 %; P = 0.006 and 0.015, respectively). Multivariate analysis confirmed that wild-type RAS was a strong predictor of optimal morphologic response [odds ratio (OR), 4.38; 95 % CI 1.45-13.15] and major pathologic response (OR, 2.61; 95 % CI 1.17-5.80). RAS mutations were independently correlated with both overall survival and recurrence free-survival (hazard ratios, 3.57 and 2.30, respectively, in model 1, and 3.19 and 2.09, respectively, in model 2). Subanalysis revealed that RAS mutational status clearly stratified survival in patients with inadequate response to preoperative chemotherapy. Conclusions RAS mutational status can be used to complement the current prognostic indicators for patients undergoing curative resection of CLM after preoperative modern chemotherapy.
    Annals of Surgical Oncology 09/2014; 22(3). DOI:10.1245/s10434-014-4042-6 · 3.94 Impact Factor
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    ABSTRACT: Purpose To retrospectively analyze factors influencing survival in patients with non-small cell lung cancer presenting with ≤3 synchronous metastatic lesions. Methods and Materials We identified 90 patients presenting between 1998 and 2012 with non-small cell lung cancer and ≤3 metastatic lesions who had received at least 2 cycles of chemotherapy followed by surgery or radiation therapy before disease progression. The median number of chemotherapy cycles before comprehensive local therapy (CLT) (including concurrent chemoradiation as first-line therapy) was 6. Factors potentially affecting overall (OS) or progression-free survival (PFS) were evaluated with Cox proportional hazards regression. Propensity score matching was used to assess the efficacy of CLT. Results Median follow-up time was 46.6 months. Benefits in OS (27.1 vs 13.1 months) and PFS (11.3 months vs 8.0 months) were found with CLT, and the differences were statistically significant when propensity score matching was used (P ≤ .01). On adjusted analysis, CLT had a statistically significant benefit in terms of OS (hazard ratio, 0.37; 95% confidence interval, 0.20-0.70; P ≤ .01) but not PFS (P=.10). In an adjusted subgroup analysis of patients receiving CLT, favorable performance status (hazard ratio, 0.43; 95% confidence interval, 0.22-0.84; P=.01) was found to predict improved OS. Conclusions Comprehensive local therapy was associated with improved OS in an adjusted analysis and seemed to favorably influence OS and PFS when factors such as N status, number of metastatic lesions, and disease sites were controlled for with propensity score–matched analysis. Patients with favorable performance status had improved outcomes with CLT. Ultimately, prospective, randomized trials are needed to provide definitive evidence as to the optimal treatment approach for this patient population.
    International journal of radiation oncology, biology, physics 09/2014; 90(4). DOI:10.1016/j.ijrobp.2014.07.012 · 4.18 Impact Factor
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    ABSTRACT: Benign or pre-cancerous lesions and foreign bodies of the stomach not amendable to endoscopic removal often require extensive surgery to address a process that does not necessitate lymph node sampling or formal gastrectomy. These lesions are particularly difficult to address endoscopically when located at the esophagogastric junction as a retroflexed view is needed. From its first description in 1995, intragastric laparoscopic surgery has evolved with respect to both technological advancements and tactical innovations. Here we report the development of four distinct techniques of laparoscopic intragastric surgery which we have developed over time and applied in 11 patients. These techniques consist of a (1) combined gastroscopic/laparoscopic approach when minimal manipulation of the lesion is needed, (2) multiport resection which provides optimal triangulation and allows for resection of more complex lesions, (3) stapled removal of broad-based lesions, and (4) single access technique with the device placed directly through the abdominal wall into the stomach. The techniques expand the surgeon's armamentarium to address more complex intragastric processes safely, while the typical postoperative benefits of minimal access surgery such as fast recovery time and less pain are preserved. As we gain greater experience with intragastric laparoscopic surgery, this technique holds the promise of becoming a standard surgical technique for benign lesions for which it is oncologically safe to perform a limited resection.
    Surgical Endoscopy 08/2014; 29(1). DOI:10.1007/s00464-014-3654-z · 3.31 Impact Factor
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    ABSTRACT: The impact of neoadjuvant therapy on postpancreatectomy complications is inadequately described.
    Gastroenterology 08/2014; 19(1). DOI:10.1007/s11605-014-2620-3 · 13.93 Impact Factor
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    ABSTRACT: The impact of first-stage resection on volume regeneration of segments 2 and 3 (2 + 3) after right portal vein embolization (RPVE) in patients undergoing two-stage right hepatectomy has not been investigated.
    Gastroenterology 08/2014; 19(1). DOI:10.1007/s11605-014-2617-y · 13.93 Impact Factor
  • Gynecologic Oncology 08/2014; 134(2):435-436. DOI:10.1016/j.ygyno.2014.04.034 · 3.69 Impact Factor
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    ABSTRACT: Background After cancer surgery, complications, and disability prevent some patients from receiving subsequent treatments. Given that an inability to complete all intended cancer therapies might negate the oncologic benefits of surgical therapy, strategies to improve return to intended oncologic treatment (RIOT), including minimally invasive surgery (MIS), are being investigated.Methods This project was designed to evaluate liver tumor patients to determine the RIOT rate, risk factors for inability to RIOT, and its impact on survivals. Outcomes for a homogenous cohort of 223 patients who underwent open-approach surgery for metachronous colorectal liver metastases and a group of 27 liver tumor patients treated with MIS hepatectomy were examined.ResultsOf the 223 open-approach patients, 167 were offered postoperative therapy, yielding a RIOT rate of 75%. The remaining 56 (25%) patients were unable to receive further treatment due to surgical complications (n = 29 pts) or poor performance status (n = 27 pts). Risk factors associated with inability to RIOT were hypertension (OR 2.2, P = 0.025), multiple preoperative chemotherapy regimens (OR 5.9, P = 0.039), and postoperative complications (OR 2.0, P = 0.039). Inability to RIOT correlated with shorter disease-free and overall survivals (P < 0.001, HR = 2.16; and P = 0.005, HR = 2.07, respectively). In contrast to the open surgery group, 100% of MIS patients who were intended to initiate postoperative therapy did so (P = 0.038) within a shorter median time interval (MIS: 15 days vs. open: 42 days; P < 0.001).Conclusions The relationship between RIOT and long-term oncologic outcomes suggests that RIOT rates for both open- and MIS-approach cancer surgery should routinely be reported as a quality indicator. J. Surg. Oncol. © 2014 Wiley Periodicals, Inc.
    Journal of Surgical Oncology 08/2014; 110(2). DOI:10.1002/jso.23626 · 2.84 Impact Factor
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    ABSTRACT: Background Reoperative surgery is suspected, but not proven, to increase postoperative complication rates. In the absence of a specific definition for reoperative surgery, the American College of Surgeons NSQIP has proposed using procedural coding for lysis of adhesions (LOA) as a surrogate for reoperative surgery to risk adjust hospitals. We hypothesized that coding of reoperative surgery will be associated with worse 30-day outcomes and, for abdominal procedures, will be more accurate than operative dictation and coding of “lysis of adhesions.” Study Design Reoperative surgery was categorized at the time of data abstraction from February 2012 to December 2012 for all NSQIP cases collected at a single institution by independent surgical clinical reviewers. Reoperative surgery classification and coding of LOA were compared with each other and with 30-day outcomes. The setting was a tertiary cancer center, multispecialty NSQIP model. During the study period, 1,289 operations were classified as nonreoperative (n = 793), regionally reoperative (n = 39; prior surgery in an adjacent area of current operation), or locally reoperative (n = 457; prior surgery at same site or organ). Results In the multispecialty cohort, the non−risk-adjusted rates of overall 30-day morbidity, serious morbidity, and mortality were 21.5%, 17.7%, and 0.5%. Compared with nonreoperative surgery (overall 30-day morbidity 16.8%, serious morbidity 13.9%, and mortality .38%), both regionally reoperative surgery (overall 30-day morbidity 30.8%, serious morbidity 28.2%, and mortality 2.5%) and locally reoperative surgery (overall 30-day morbidity 28.9%, serious morbidity 23.4%, and mortality .66%) were associated with worse outcomes (p < 0.001). One hundred ninety-nine of the 327 gastrointestinal/laparotomy cases were recorded as reoperative, but only of 20 of these were CPT coded as LOA (sensitivity = 10%). Conclusions Reoperative surgery is frequent, increases the risk of complications, and can be captured. Operative LOA coding vastly under reports reoperative surgery and, therefore, is not an adequate surrogate for this important risk factor.
    Journal of the American College of Surgeons 07/2014; 219(1):143–150. DOI:10.1016/j.jamcollsurg.2014.03.024 · 4.45 Impact Factor
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    ABSTRACT: Background A well-defined treatment strategy for elderly patients with resectable pancreatic cancer is lacking. Multiple reports have described highly selected older cancer patients who have successfully undergone pancreatectomy. However, multimodality therapy is essential for long-term survival, and elderly patients are at high risk for not receiving adjuvant therapy postoperatively. We sought to describe the treatment patterns and outcomes of a series of elderly patients with pancreatic cancer who were treated with a multimodality strategy which liberally employed neoadjuvant therapy. Study Design The treatment plan, short-term outcomes and overall survival of all patients 70+ years old presenting to our institution over a 9-year period who were treated for anatomically resectable pancreatic cancer were retrospectively reviewed. Results 179 (76%) of 236 patients with resectable pancreatic cancer were treated with curative intent. 153 (85%) of these patients initiated neoadjuvant therapy: 74 (48%) subsequently underwent pancreatectomy and 79 did not due to disease progression (n=46), insufficient performance status (n=23), or other reasons (n=10). Eleven (42%) of 26 patients who underwent surgery first received postoperative therapy. Among patients treated with curative intent, the median overall survival of all patients initiating neoadjuvant therapy (16.6 [range, 2.1–142.7] months) was similar to that of patients undergoing resection primarily (15.1 [range, 5.4–100.8] months), p = 0.53. Following pancreatectomy, patients had a 2% in-hospital mortality rate and 91% were discharged home. Conclusion 85% of all patients 70+ years old who underwent pancreatectomy for anatomically resectable pancreatic cancer received multimodality therapy. Over 90% were discharged home. These data demonstrate a potential role for neoadjuvant therapy in selecting elderly patients for surgery, and support further studies to refine individualized treatment protocols for this high-risk population.
    Journal of the American College of Surgeons 07/2014; 219(1). DOI:10.1016/j.jamcollsurg.2014.02.023 · 4.45 Impact Factor
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    ABSTRACT: Background. For patients with synchronous liver and lung metastases from colorectal cancer, the invasiveness of adding thoracic to abdominal surgery is an obstacle to concurrent liver and lung metastasectomy. We developed a simple technique to resect lung lesions via a transdiaphragmatic approach without thoracic incision in patients undergoing liver metastasectomy. Methods. Sixteen patients with synchronous liver and unilateral lung metastases underwent transdiaphragmatic wedge resection of lung lesions simultaneous with liver metastasectomy. Short-term operative outcomes were compared with those in 102 patients treated with conventional unilateral wedge resection for colorectal lung metastases. Results. Twenty peripheral (<3 cm from the pleura) lung lesions from various locations in the lung were resected via transdiaphragmatic approach. No conversions to conventional approach were required. The median tumor number and size were I (range, 1-3) and 8 mm (range, 3-30 mm), respectively. Transdiaphragmatic resection reduced median operative blood loss compared with conventional resection (0 mL vs 50 mL [P < .0011) and reduced median duration of hospital stay compared with staged liver and lung resection (6 days vs 11 days [P < .001]). Operative duration and rates of lung-related morbidity and positive surgical margin were similar between the transdiaphragmatic and conventional groups (104 minutes vs 105 minutes [P = .61], 13% vs 4% [P = .15], and 6% vs 5% [P = .73], respectively). Conclusion. Simultaneous transdiaphragmatic resection of peripheral lung lesions is safe in patients undergoing liver resection. The low-invasive transdiaphragmatic approach facilitates aggressive operative treatment for synchronous liver and lung metastases.
    Surgery 06/2014; 156(5). DOI:10.1016/j.surg.2014.04.050 · 3.11 Impact Factor

Publication Stats

2k Citations
574.81 Total Impact Points

Institutions

  • 2014
    • University of Houston
      Houston, Texas, United States
  • 2005–2014
    • University of Texas MD Anderson Cancer Center
      • • Department of Surgical Oncology
      • • Department of Surgery
      Houston, Texas, United States
  • 2012
    • Fox Chase Cancer Center
      Filadelfia, Pennsylvania, United States
  • 2009–2010
    • Weill Cornell Medical College
      • Department of Surgery
      New York, New York, United States
    • Robert Wood Johnson University Hospital
      New Brunswick, New Jersey, United States
  • 2008–2010
    • Houston Methodist Hospital
      Houston, Texas, United States
    • Methodist Hospitals
      Gary, Indiana, United States
    • University Medical Center Utrecht
      Utrecht, Utrecht, Netherlands
    • Rice University
      Houston, Texas, United States
  • 2007–2009
    • Baylor College of Medicine
      • • Department of Surgery
      • • Department of Medicine
      Houston, TX, United States
    • Assistance Publique – Hôpitaux de Paris
      Lutetia Parisorum, Île-de-France, France
  • 2006
    • Hôpital Paul-Brousse – Hôpitaux universitaires Paris-Sud
      Villejuif, Île-de-France, France