Attila Nakeeb

Indiana University-Purdue University School of Medicine, Indianapolis, Indiana, United States

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Publications (126)813.61 Total impact

  • Pancreatology 11/2015; DOI:10.1016/j.pan.2015.11.005 · 2.84 Impact Factor
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    ABSTRACT: Objective: Determine drivers of academic productivity within U.S. departments of surgery. Methods: Eighty academic metrics for 3,850 faculty at the top 50 NIH-funded university- and 5 outstanding hospital-based surgical departments were collected using websites, Scopus, and NIH RePORTER. Results: Mean faculty size was 76. Overall, there were 35.3% assistant, 27.8% associate, and 36.9% full professors. Women comprised 21.8%; 4.9% were MD-PhDs and 6.1% PhDs. By faculty-rank, median publications/citations were: assistant, 14/175, associate, 39/649 and full-professor, 97/2250. General surgery divisions contributed the most publications and citations. Highest performing sub-specialties per faculty member were: research (58/1683), transplantation (51/1067), oncology (41/777), and cardiothoracic surgery (48/860). Overall, 23.5% of faculty were principal investigators for a current or former NIH grant, 9.5% for a current or former R01/U01/P01. The 10 most cited faculty (MCF) within each department contributed to 42% of all publications and 55% of all citations. MCF were most commonly general (25%), oncology (19%), or transplant surgeons (15%). Fifty-one-percent of MCF had current/former NIH funding, compared with 20% of the rest (p<0.05); funding rates for R01/U01/P01 grants was 25.1% vs. 6.8% (p<0.05). Rate of current-NIH MCF funding correlated with higher total departmental NIH rank (p < 0.05). Conclusions: Departmental academic productivity as defined by citations and NIH funding is highly driven by sections or divisions of research, general and transplantation surgery. MCF, regardless of subspecialty, contribute disproportionally to major grants and publications. Approaches that attract, develop, and retain funded MCF may be associated with dramatic increases in total departmental citations and NIH-funding.
    PLoS ONE 07/2015; 10(7):e0131678. DOI:10.1371/journal.pone.0131678 · 3.23 Impact Factor
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    ABSTRACT: It is unclear whether the duct involvement subtypes of intraductal papillary mucinous neoplasm (IPMN), ie, main (MD), mixed (MT), and branch (BD), confer any survival advantage when invasive IPMN occurs. We hypothesized that invasive MT-IPMN was associated with a better prognosis than invasive MD-IPMN. A retrospective review of a prospectively maintained database was performed of patients who underwent resection for IPMN at a single academic institution from 1992 to 2014. Characterization of IPMN subtype was assessed on final operative pathology. Statistics included univariate analysis, Kaplan-Meier survival curves, and Cox regression for independent predictors of increased survival. Of 390 patients eligible for study, 74 had invasive IPMN (IPMC). Of these, 71 patients had complete data and were included in the analysis (17 MD-IPMC, 39 MT-IPMC, and 15 BD-IPMC). Median follow-up was 20 months (range, 2-174). MT-IPMC was associated with significantly greater overall survival (OS) (47 months) compared with MD-IPMC (12 months) (P = .049), but not with BD-IPMC (44 months) (P = .67). Multivariate Cox regression yielded a family history of pancreatic cancer, absence of jaundice, N0 status, negative margins, absence of lymphovascular invasion, and MT subtype as independent predictors of greater OS (P = .035, .015, .013, .036, .045, .043, respectively). No characteristic of IPMN (including MD diameter, solid component/mural nodule) was predictive of OS. MT-IPMC appeared to be associated with a greater OS compared with pure MD-IPMC. This begs the question of a different underlying biology of MT-IPMN and argues against classification of all main duct involved IPMN into a single category. Copyright © 2015 Elsevier Inc. All rights reserved.
    Surgery 07/2015; 158(4). DOI:10.1016/j.surg.2015.06.003 · 3.38 Impact Factor
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    ABSTRACT: Recent analyses of gastrointestinal operations document that complications are a key driver of readmissions. Pancreatectomy is a high outlier with respect to readmission. This analysis sought to determine if a multifactorial approach could reduce readmissions after pancreatectomy. From 2007 to 2012, the number of patients readmitted by 30 days after pancreaticoduodenectomy, and distal and total pancreatectomy was measured. Steps to decrease readmissions were implemented independently at 1-year intervals; these efforts included strategies to reduce complications, creation of a Readmissions Team with a "discharge coach," increased use of home health, preferred relationships with post-acute care facilities, and the adoption of "Project RED" (Re-Engineered Discharge). The ACS NSQIP was used to track 30-day outcomes for all pancreatic resections. The University HealthSystem Consortium was used to determine length of stay index. Over 5 years, 1,163 patients underwent proximal (66%), distal (32%), or total pancreatectomy (2%). The observed 30-day mortality was 2.9% for the study period, and the length of stay index (observed/expected days) was 1.10. Neither varied significantly over time. However, 30-day morbidity decreased from 57% to 46%, and proportion of patients with 30-day all-cause readmissions decreased from 23.0% to 11.5% (p = 0.001). All-cause 30-day readmissions after pancreatectomy decreased without increasing length of stay. Efforts by surgeons to decrease complications and an increased emphasis on coordination of care may be useful for reducing readmissions. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Surgeons 05/2015; 221(3). DOI:10.1016/j.jamcollsurg.2015.05.012 · 5.12 Impact Factor
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    ABSTRACT: Pancreatic fistula remains the primary source of morbidity following distal pancreatectomy. Previous studies have reported specific methods of parenchymal transection/stump sealing in an effort to decrease the pancreatic fistula rate with highly variable results. The aim of this study was to determine postoperative outcomes following various pancreatic stump-sealing methods. All cases of distal pancreatectomy were reviewed at a single institution between January 2008 and June 2011 and were monitored with complete 30-day outcomes through ACS-NSQIP. Pancreatic stump-sealing method was used to create three operation groups (suture, staple, or saline-linked radiofrequency). Two- and three-way statistical analyses were performed among the operation groups. Two hundred three patients underwent distal pancreatectomy. The most common diagnoses included chronic pancreatitis, adenocarcinoma, and IPMN. The suture, staple, and SLRF groups included 90 (44 %), 61 (30 %), and 52 (26 %) patients, respectively. Overall complications (range 31-38 %) and pancreatic fistula (range 25-26 %) were similar with each pancreatic closure technique. Operative technique was not associated with an increased need for postoperative interventions or hospital readmission. Postoperative outcomes after distal pancreatectomy are unaffected by the use of SLRF sealing of the pancreatic stump when compared to traditional suture or reinforced stapling techniques.
    Journal of Gastrointestinal Surgery 04/2015; 19(8). DOI:10.1007/s11605-015-2825-0 · 2.80 Impact Factor

  • Gastroenterology 04/2015; 148(4):S-1121. DOI:10.1016/S0016-5085(15)33820-8 · 16.72 Impact Factor
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    ABSTRACT: Intraductal papillary mucinous neoplasms (IPMNs) are well-established pancreatic precancerous lesions. Indications for resection are outlined in the 2012 International Consensus Guidelines (ICG). Because of the low specificity of the ICG, many patients will undergo potentially unnecessary surgery for nonmalignant IPMNs. Several retrospective studies have reported that positron emission tomography (PET) with CT (PET/CT) is highly sensitive and specific in detecting malignant IPMNs. We hypothesized that PET/CT complements the ICG in identification of malignant IPMNs. From 2009 to 2013, patients with a suspected clinical or cytopathologic diagnosis of IPMN were prospectively enrolled in a clinical trial at a single center. Results of preoperative PET/CT on determination of IPMN malignancy (ie, high-grade dysplastic and invasive) was compared with surgical pathology. PET/CT uptake was considered increased if the standardized uptake value was ≥3. Of the 67 patients enrolled, 50 patients met all inclusion criteria. Increased PET/CT uptake was associated with significantly more malignant and invasive IPMNs (80% vs 13%; p < 0.0001 and 40% vs 3%; p = 0.004). When patients were divided into branch duct and main duct IPMNs, increased PET/CT uptake was also associated with more malignancy (60% vs 0%; p = 0.006 for branch duct IPMN and 100% vs 23%; p = 0.003 for main duct IPMN). Patients with ICG criteria (eg, worrisome features and high-risk stigmata) and increased PET/CT uptake had more malignant and invasive IPMNs than patients with ICG criteria, but no increased uptake (78% vs 17%; p = 0.001 and 33% vs 3%; p = 0.03). The sensitivity and specificity of the ICG criteria for detecting malignancy were 92% and 27%, respectively, and PET/CT was less sensitive (62%) but more specific (95%). When PET/CT was added to ICG criteria, the association resulted in 78% sensitivity and 100% specificity. The addition of PET/CT to preoperative workup improves the performance of the ICG for predicting malignant risk in patients with IPMN. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Surgeons 04/2015; 221(1). DOI:10.1016/j.jamcollsurg.2015.04.020 · 5.12 Impact Factor
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    ABSTRACT: Introduction: The natural history of radiographic strictures of the pancreaticojejunostomy (PJ) after pancreatoduodenectomy (PD) is difficult to characterize. The purpose of this study was to identify the indications for operative revision of PJ strictures after PD for benign and malignant disease and to evaluate its safety and clinical efficacy. Methods: A retrospective review of all patients undergoing operative revision of PJ strictures following PD at a single academic institution over an 8-year period (2006-2014) was performed. Results: Twenty-seven patients underwent revision of a symptomatic radiographically detectable PJ stricture. The median time from PD to PJ stricture diagnosis was 46 months. The median increase in the main pancreatic duct diameter between the time of PD and PJ revision was 2 mm. The overall morbidity after PJ revision was 26 %. No postoperative mortality occurred. Twenty-one (78 %) patients experienced resolution of symptoms without recurrent acute pancreatitis after PJ revision during a median follow-up of 30 months. Durable symptom resolution was reported among 60 % of patients with chronic pancreatitis. Conclusions: Surgical revision of pancreaticojejunostomy strictures is technically safe and clinically effective for selected patients who experience recurrent acute pancreatitis after pancreatoduodenectomy for either benign or malignant disease.
    Gastroenterology 04/2015; 148(4):S-1119-S-1120. DOI:10.1016/S0016-5085(15)33817-8 · 16.72 Impact Factor
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    ABSTRACT: Marginal ulcer (MU) is a well-described complication of pancreatoduodenectomy (PD) whose incidence remains unclear. Gastric antisecretory medications likely attenuate the risk of marginal ulceration after PD; however, the true relationship between antisecretory medication and marginal ulceration after PD is not precisely known. The aims of this study were to document the incidence of MU after PD, identify any relationship between MU and gastric antisecretory medication, and survey current practice of MU prophylaxis among experienced pancreatic surgeons. the MEDLINE, EMBASE, Cochrane Central Registrar of Controlled Trials, and Cochrane Database of Systematic Reviews databases were searched from their inception to May 2014 for abstracts documenting ulceration after pancreatoduodenectomy. Two reviewers independently graded abstracts for inclusion in this review. Contemporary practice was assessed through a four-question survey distributed globally to 200 established pancreatic surgeons. After a review of 208 abstracts, 54 studies were graded as relevant. These represented a cohort of 212 patients with marginal ulcer after PD (n = 4794). A meta-analysis of the included references shows mean incidence of ulceration after PD of 2.5 % (confidence interval (CI) 1.8-3.2 %) with a median time to diagnosis of 15.5 months. Pylorus preservation was associated with a MU rate of 2.0 % (CI 1.0-2.9 %), while "classic" PD procedures report an overall rate of 2.6 % (CI 1.6-3.6 %). Documented use of postoperative antisecretory medication was associated with a reduced rate of 1.4 % (CI 0.1-1.7 %). One hundred forty-four of 200 (72 %) surveys were returned, from which it was determined that 92 % of pancreatic surgeons have dealt with this complication, and 86 % routinely prescribe prophylactic antisecretory medication after PD. The incidence of MU after PD is 2.5 % with a median time to occurrence of 15.5 months postoperatively. Gastric antisecretory medication prescription may affect the incidence of MU. The majority of pancreatic surgeons surveyed have encountered MU after PD; most (86 %) routinely prescribe prophylactic gastric antisecretory medication.
    Journal of Gastrointestinal Surgery 02/2015; 19(4). DOI:10.1007/s11605-015-2765-8 · 2.80 Impact Factor
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    ABSTRACT: Patients with adenocarcinoma of the pancreatic body/tail and associated vascular thrombosis or adjacent organ invasion are suboptimal candidates for resection. We hypothesized that extended distal pancreatectomy (EDP) for locally advanced adenocarcinoma is associated with a survival benefit. We retrospectively reviewed a prospectively collected database of patients who underwent distal pancreatectomy (DP) for adenocarcinoma at a single academic institution (1996 to 2011) with greater than or equal to 2 years of follow-up. Among 680 DP patients, 93 were indicated for pancreatic adenocarcinoma. Splenic vein thrombosis (n = 26) did not significantly affect morbidity, mortality, or survival. Standard DP was performed in 70 patients and 23 underwent EDP with no difference in morbidity/mortality. Patients with EDP had a survival comparable with patients with standard DP (disease-free survival 18 vs 12 months = .8; overall survival 23 vs 17 months, P =.6). There was no difference in survival between EDP patients with versus without pathologic invasion of adjacent organs, but a trend favored those without. EDP is safe and should be considered in fit patients with locally advanced adenocarcinoma. Copyright © 2015 Elsevier Inc. All rights reserved.
    The American Journal of Surgery 12/2014; 209(3). DOI:10.1016/j.amjsurg.2014.10.017 · 2.29 Impact Factor
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    ABSTRACT: Introduction Pancreatitis is associated with intraductal papillary mucinous neoplasm (IPMN). This association is in part due to inflammation from pancreatic ductal obstruction. Although the correlation between pancreatitis and the malignant potential of IPMN is unclear, the 2012 International Consensus Guidelines (ICG) consider pancreatitis a “worrisome feature.” We hypothesized that serum pancreatic enzymes, markers of inflammation, are a better predictor of malignancy than pancreatitis in patients with IPMN. Methods Between 1992 and 2012, 364 patients underwent resection for IPMN at a single university hospital. In the past decade, serum amylase and lipase were collected prospectively as an inflammatory marker in 203 patients with IPMN at initial surveillance and “cyst clinic” visits. The latest serum pancreatic enzyme values within 3 months preoperatively were studied. Pancreatitis was defined according to the 2012 revision of the Atlanta Consensus. Results Of the 203 eligible patients, there were 76 with pancreatitis. Pancreatitis was not associated with an increased rate of malignancy (P = .51) or invasiveness (P = .08). Serum pancreatic enzymes categorically outside of normal range (high or low) were also not associated with malignancy or invasiveness. In contrast, as a continuous variable, the higher the serum pancreatic enzymes were, the greater the rate of invasive IPMN. Of the 127 remaining patients without pancreatitis, serum pancreatic enzymes outside of normal range (low and high) were each associated with a greater rate of malignancy (P < .0001 and P = .0009, respectively). Serum pancreatic enzyme levels above normal range (high) were associated with a greater rate of invasiveness (P = .02). Conclusion In patients with IPMN without a history of pancreatitis, serum pancreatic enzymes outside of the normal range are associated with a greater risk of malignancy. In patients with a history of pancreatitis, there is a positive correlation between the levels of serum pancreatic enzymes and the presence of invasive IPMN. These data suggest serum pancreatic enzymes may be useful markers in stratification of pancreatic cancer risk in patients with IPMN.
    Surgery 10/2014; 156(4):923–930. DOI:10.1016/j.surg.2014.07.010 · 3.38 Impact Factor

  • Journal of the American College of Surgeons 10/2014; 219(4):e21-e22. DOI:10.1016/j.jamcollsurg.2014.07.442 · 5.12 Impact Factor
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    ABSTRACT: As such, the natural history of MPD-involved IPMN is poorly understood.
    Annals of Surgery 10/2014; 260(4):680-690. DOI:10.1097/SLA.0000000000000927 · 8.33 Impact Factor
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    ABSTRACT: Purpose: The aim of this study was to determine if early recognition and treatment of delayed gastric emptying (DGE) can augment postoperative outcomes in patients undergoing pancreatectomy. Methods: The International Study Group of Pancreatic Surgery definition of DGE was used to identify patients at Indiana University Hospital who required supplemental nutrition for DGE after pancreatectomy. Outcomes were compared between those without DGE, those with DGE who received supplemental nutrition within 10 days after pancreatectomy (early intervention), and those treated after 10 days (late intervention). Results: Between 2007 and 2012, the incidence of DGE was 15% (n = 163/1,089), 45% (n = 73) required supplemental nutrition, including 60% (n = 44/73) in the early intervention and 40% (n = 29/73) in the late intervention groups. Postoperative morbidity (62% vs 41%; P < .01), duration of stay (16 vs 7 days; P < .01), and readmissions (41% vs 17%; P < .01) were greater among those with DGE. The early intervention group resumed a regular diet sooner (day 24 vs 36; P = .05) and were readmitted less often (25% vs 65%; P < .01) than those in the late intervention group. Treatment-related complications occurred in 14% of patients. Conclusion: Patients with DGE can be managed with acceptable treatment-related morbidity. Outcomes are best when supplemental nutrition is started within 10 days of operation.
    Surgery 08/2014; 156(4). DOI:10.1016/j.surg.2014.06.024 · 3.38 Impact Factor
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    ABSTRACT: Objectives:: Adjuvant therapy after surgical resection is the current standard for pancreatic adenocarcinoma; however, the role of chemoradiotherapy (CRT) remains unclear. This study was conducted to compare the efficacy outcomes with adjuvant gemcitabine and gemcitabine-based CRT (CT-CRT) versus gemcitabine chemotherapy (CT) alone after pancreaticoduodenectomy. Methods:: Among 165 patients who underwent surgical resection for pancreatic cancer at Indiana University Medical Center between 2004 and 2008, we retrospectively identified 53 consecutive patients who received adjuvant therapy (CT-CRT=34 patients; CT=19 patients) and had adequate follow-up medical records. The median follow-up was 19.1 months. Median disease-free (DFS) and overall survival (OS) were determined using Kaplan-Meier method, and a Cox-regression model was used to compare survival outcomes after adjusting for age, status of resection margins, and lymph node involvement. Results:: The OS for the CT-CRT group was significantly higher compared with the CT group (median, 20.4 vs. 16.6 mo; hazard ratio, 2.42; 95% CI, 1.17-5.01). The median DFS for the CT-CRT group was 13.7 versus 11.1 months for the CT group (hazard ratio, 2.88; 95% CI, 1.37-6.06). On subgroup analyses, significantly superior OS and DFS were observed among patients younger than 65 years, T3/T4 tumor stage, negative resection margins, and positive lymph node involvement. Conclusion:: Gemcitabine plus gemcitabine-based CRT compared with gemcitabine alone leads to superior DFS and OS for patients with resected pancreatic cancer.
    American Journal of Clinical Oncology 08/2014; DOI:10.1097/COC.0000000000000115 · 3.06 Impact Factor

  • Gastroenterology 05/2014; 146(5):S-1068. DOI:10.1016/S0016-5085(14)63895-6 · 16.72 Impact Factor

  • Gastroenterology 05/2014; 146(5):S-1044-S-1045. DOI:10.1016/S0016-5085(14)63807-5 · 16.72 Impact Factor

  • Gastroenterology 05/2014; 146(5):S-1069. DOI:10.1016/S0016-5085(14)63898-1 · 16.72 Impact Factor
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    ABSTRACT: Background: Although the natural history of intraductal papillary mucinous neoplasm (IPMN) remains unclear, large surgical series have reported malignancy in 40% to 90% of main pancreatic duct (MPD)-involved IPMN. Accordingly, the 2012 International Consensus Guidelines recommend surgical resection in patients with suspected MPD involvement. We hypothesized that nonoperative management of select patients with suspected MPD-involved IPMN might be indicated. Study design: From 1992 to 2012, 362 patients underwent surgical resection for pathologically confirmed IPMN at a single academic center. A retrospective review of prospectively collected data was performed. Main pancreatic duct involvement was suspected with an MPD diameter ≥5 mm on preoperative imaging. A multivariate analysis was conducted to assess predictors of malignancy. Results: Of 362 patients, 334 had complete data for analysis. Main pancreatic duct involvement was suspected preoperatively in 171 patients. Final pathology revealed 20% high-grade dysplastic and 27% invasive IPMN (47% malignant). Preoperative cytopathology and serum carbohydrate antigen 19-9 independently predicted malignancy (p = 0.003 and p = 0.002, respectively) and invasiveness (p < 0.0001 and p = 0.001, respectively). Patients with both negative preoperative cytopathology and normal serum carbohydrate antigen 19-9 (ie, double negatives) had a lower rate of malignancy and invasiveness (28% and 8% vs 58% and 38%; p < 0.0001). The MPD diameter did not predict malignancy or invasiveness (p = 0.36 and p = 0.46, respectively). Conclusions: Patients with suspected MPD-involved IPMN have a highly variable rate of malignancy. Despite recent International Consensus Guidelines recommendations, these data suggest that MPD diameter is not an optimal gauge of malignant risk. Nonoperative management of suspected MPD-involved IPMN in select patients, particularly double negatives, might be indicated. Depending on age and comorbidity, operative risk might outweigh the risk of malignant progression in these patients.
    Journal of the American College of Surgeons 03/2014; 219(1). DOI:10.1016/j.jamcollsurg.2014.03.021 · 5.12 Impact Factor
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    ABSTRACT: Pancreaticoduodenectomy (PD) remains a challenging operation with a 40 % postoperative complication rate. Pyogenic liver abscess (PLA) is an uncommon complication following PD with little information on its incidence or treatment. This study was done to examine the incidence, risk factors, treatment, and long-term outcome of PLA after PD. We retrospectively reviewed 1,189 patients undergoing PD (N = 839) or distal pancreatectomy (DP) (N = 350) at a single institution over a 14-year period (January 1, 1994-January 1, 2008). Pancreatic databases (PD and DP) were queried for postoperative complications and cross-checked through a hospital-wide database using ICD-9 codes 572.0 (PLA) and 006.3 (amebic liver abscess) as primary or secondary diagnoses. No PLA occurred following DP. Twenty-two patients (2.6 %) developed PLA following PD. These 22 patients were matched (1:3) for age, gender, year of operation, and indication for surgery with 66 patients without PLA following PD. PLA occurred in 2.6 % (22/839) of patients following PD, with 13 patients (59.1 %) having a solitary abscess and 9 (40.9 %) multiple abscesses. Treatment involved antibiotics and percutaneous drainage (N = 15, 68.2 %) or antibiotics alone (N = 7, 31.8 %) with a mean hospital stay of 12 days. No patient required surgical drainage, two abscesses recurred, and all subsequently resolved. Three patients (14 %) died related to PLA. Postoperatively, patients with biliary fistula (13.6 vs. 0 %, p = 0.014) or who required reoperation (18.2 vs. 1.5 %, p = 0.013) had a significantly higher rate of PLA than matched controls. Long-term follow-up showed equivalent 1-year (79 vs.74 %), 2-year (50 vs. 57 %), and 3-year (38 vs. 33 %) survival rates and hepatic function between patients with PLA and matched controls. Postoperative biliary fistula and need for reoperation are risk factors for PLA following PD. Antibiotics and selective percutaneous drainage was effective in 86 % of patients with no adverse effects on long-term hepatic function or survival.
    Journal of Gastrointestinal Surgery 02/2014; 18(5). DOI:10.1007/s11605-014-2466-8 · 2.80 Impact Factor

Publication Stats

3k Citations
813.61 Total Impact Points


  • 2015
    • Indiana University-Purdue University School of Medicine
      • Surgery
      Indianapolis, Indiana, United States
  • 2004-2015
    • Indiana University-Purdue University Indianapolis
      • Department of Surgery
      Indianapolis, Indiana, United States
  • 2014
    • Massachusetts General Hospital
      • Department of Surgery
      Boston, Massachusetts, United States
  • 2011
    • Universidade Federal de São Paulo
      San Paulo, São Paulo, Brazil
    • University of Wisconsin–Madison
      • School of Medicine and Public Health
      Madison, Wisconsin, United States
  • 2010
    • Virginia Commonwealth University
      Ричмонд, Virginia, United States
    • University of Miami Miller School of Medicine
      Miami, Florida, United States
  • 2001-2009
    • Medical College of Wisconsin
      • Department of Surgery
      Milwaukee, WI, United States
  • 1995-2001
    • Johns Hopkins Medicine
      • Department of Surgery
      Baltimore, MD, United States
  • 2000
    • University of Wisconsin - Milwaukee
      Milwaukee, Wisconsin, United States