Conor P Delaney

Case Western Reserve University, Cleveland, Ohio, United States

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Publications (231)853.28 Total impact

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    ABSTRACT: Superior early pain control has been suggested with transversus abdominis plane blocks, but evidence-based recommendations for transversus abdominis plane blocks and their effects on patient outcomes are lacking.
    Diseases of the Colon & Rectum 11/2014; 57(11):1290-1297. · 3.34 Impact Factor
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    ABSTRACT: To establish a structured international expert consensus on a detailed technical description of the laparoscopic total mesorectal excision (TME).
    Annals of surgery. 07/2014;
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    ABSTRACT: Surgical Telementoring using a tablet - bridges two continents In January 2014, Dr. Conor Delaney and Dr. Knut Magne Augestad at University Hospitals Case Medical Center assisted Dr. Rolv-Ole Lindsetmo at University Hospital North Norway, 6500 miles apart, in the first transatlantic telementored surgical sessions ever performed using a tablet PC. Two patients with colorectal cancer were operated on in Norway, and during the surgeries the US based team assisted in identifying key anatomical locations and surgical planes for dissection. “Telementoring on tablet PCs is a fascinating and innovative solution,” says Professor Conor Delaney, Chief of the Department of Colorectal Surgery, University Hospitals Case Medical Center in Cleveland. “The fact that we were able to perform transatlantic telestration (drawings over a live videostream) enhanced the mentors teaching capabilities and made it so much easier to reach a common agreement on the key surgical anatomical locations. The mobility of the technology is also of key importance, as mentors can connect to any Wi-fi or fast HSPA (High speed packet access) 3G-cellphone network, or the new or the new LTE (4G) mobile network. In a busy hospital workday, this is a huge advantage,” says Dr. Delaney. In Norway, Dr. Lindsetmo, chief at the Department of Gastrointestinal Surgery, University Hospital North Norway, is in charge of a hospital telementoring network. “At present we aim to connect several local hospitals to a University Hospital. This will contribute to build surgeon-networks that have the potential of helping surgeons out of difficult situations in the operating theatre.
    06/2014;
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    ABSTRACT: Most patients treated with curative intent for colorectal cancer (CRC) are included in a follow-up program involving periodic evaluations. The survival benefits of a follow-up program are well delineated, and previous meta-analyses have suggested an overall survival improvement of 5%-10% by intensive follow-up. However, in a recent randomized trial, there was no survival benefit when a minimal vs an intensive follow-up program was compared. Less is known about the potential side effects of follow-up. Well-known side effects of preventive programs are those of somatic complications caused by testing, negative psychological consequences of follow-up itself, and the downstream impact of false positive or false negative tests. Accordingly, the potential survival benefits of CRC follow-up must be weighed against these potential negatives. The present review compares the benefits and side effects of CRC follow-up, and we propose future areas for research.
    World journal of gastrointestinal oncology. 05/2014; 6(5):104-111.
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    ABSTRACT: There is an increasing trend to use laparoscopy for rectal cancer surgery. Although laparoscopic and open rectal resections appear oncologically equivalent, there is little information on the cost of different surgical approaches. With the current health care crisis and the importance of optimizing health care resources and patient outcomes, the cost of care is an important factor. The aim of this study was to evaluate the cost-effectiveness of laparoscopy in rectal cancer. This was a case-matched study. This study was conducted at a tertiary referral center. Patients undergoing elective rectal cancer resection between 2007 and 2012 were selected. A review of a prospective database for elective laparoscopic rectal cancer resections was performed. Laparoscopic cases were matched to open cases based on age, BMI, operative procedure, and diagnostic-related group. The primary outcomes measured were the cost of care, hospital length of stay, discharge disposition, readmission, postoperative complications, and mortality rates. Two hundred fifty-four matched cases were included in the analysis: 125 laparoscopic (49%) and 129 open (51%). The cTNM stage (p = 0.39), tumor distance from the anal verge (p = 0.07), and rate of neoadjuvant therapy received between the laparoscopic and open groups were similar (p = 0.12). Operating time (p< 0.01) and cost per operating room minute (p = 0.04) were significantly higher in the open group. The groups were oncologically equivalent, based on circumferential resection margin (p = 0.15). The laparoscopic group had a significantly shorter length of stay (p < 0.01) and lower total hospital cost (p < 0.01). Postoperative complications, 30-day readmission, reoperation, and mortality rates were similar. However, significantly more patients undergoing open resection required intensive care unit care (p = 0.03), skilled nursing (p = 0.03), or home care services (p < 0.01) at discharge. This investigation was conducted at a single institution and it is a retrospective study with potential bias. Laparoscopy is cost-effective for rectal cancer surgery, improving both health care expenditures and patient outcomes. For selected patients, laparoscopic rectal cancer resection can reduce length of stay, operating time, and resource utilization.
    Diseases of the Colon & Rectum 05/2014; 57(5):564-9. · 3.34 Impact Factor
  • Annals of surgery 03/2014; · 7.90 Impact Factor
  • Liane S Feldman, Conor P Delaney
    Surgical Endoscopy 03/2014; · 3.43 Impact Factor
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    ABSTRACT: The overall aim was to develop and validate a risk prediction score for laparoscopic colorectal surgery training cases. Published risk prediction scores are not transferable between hospitals because they are derived from a single institution's data and are not designed for use in training situations. Cases from the prospectively collected database of the National Training Programme in Laparoscopic Colorectal Surgery, between July 2008 and July 2012, were analyzed. Independent risk factors for conversion were identified by the logistic regression. Converting the odds ratios into integers created a risk prediction score for conversion. The clinical impact of this score was investigated by comparing postoperative complications and the level of trainer input in high- and low-risk cases. To study whether adverse outcomes in predicted high-risk cases occur outside the National Training Programme in Laparoscopic Colorectal Surgery, 2 external data sets were examined. A total of 2341 cases carried out in 42 hospitals were analyzed. Significant risk factors for conversion were body mass index, American Society of Anesthesiology classification, male sex, prior abdominal surgery, and resection type. At a risk score of more than 6, complication rates increased, including mortality (2.9% vs 0.5%, P < 0.001), anastomotic leak (4.3% vs 1.4%, P = 0.002), and a higher level of trainer input (32.2% vs 19.9% of cases, P < 0.001). Analysis of 786 external cases showed that high-risk cases had higher conversion (18.8% vs 7.1%, P < 0.001), overall complication (36.4% vs 15.0%, P < 0.001), and leak rates (4.0% vs 1.3%, P = 0.015). A risk predication score to facilitate case selection in laparoscopic colorectal surgery training was developed and validated.
    Annals of surgery 03/2014; · 7.90 Impact Factor
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    ABSTRACT: Several studies have demonstrated skills transfer after virtual reality (VR) simulation training in laparoscopic surgery. However, the impact of VR simulation training on transfer of skills related to laparoscopic colectomy remains not investigated. The present study aimed at determining the impact of VR simulation warm-up on performance during laparoscopic colectomy in the porcine model. Fourteen residents naive to laparoscopic colectomy as surgeons were randomly assigned in block to two groups. Seven trainees completed a 2-h VR simulator training in the laparoscopic sigmoid colectomy module (study group). The remaining seven surgeons (control group) underwent no intervention. On the same day, all participants performed a sigmoid colectomy with anastomosis on a pig. All operations were video recorded. Two board-certified expert colorectal surgeons independently assessed performance during the colectomy on the swine. Examiners were blinded to group assignment. The two examiners used a previously validated clinical instrument specific to laparoscopic colectomy. The primary outcome was the generic and specific skills score values. Surgeons undergoing short-duration training on the VR simulator performed significantly better during laparoscopic colectomy on the pig regarding general and specific technical skills evaluation. The average score of generic skills was 17.2 (16.5-18) for the control group and 20.1 (16.5-22) for the study group (p = 0.002). The specific skills average score for the control group was 20.2 (19-21.5) and 24.2 (21-27.5) for the study group (p = 0.001). There was acceptable concordance (Kendall's W) regarding the video assessment of generic (W = 0.78) and specific skills (W = 0.84) between the two examiners. A single short-duration VR simulator practice positively impacted surgeons' generic and specific skills performance required to accomplish laparoscopic colectomy in the swine model.
    Surgical Endoscopy 03/2014; · 3.43 Impact Factor
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    ABSTRACT: Despite laparoscopy and enhanced recovery pathways, some patients do not attain early discharge. Frailty is generally accepted as a marker of increased risk, complications, and mortality. Frailty may have the potential to identify patient outcomes. The aim of this study was to evaluate frailty as a predictor of patients who might fail early discharge. This study was conducted at a tertiary referral center. This was a case-matched study. Elective abdominal laparoscopic colorectal cases from 2009 to 2012 were selected. Review of a prospective database matched all cases with a postoperative day of discharge of ≤3 days to a >3 day of discharge cohort. All patients followed a standardized enhanced recovery pathway. Categorical and ordinal variables were analyzed with the Student t test or Fisher exact test, and correspondence analysis evaluated the relationship between length of stay and the Modified Frailty Index. The primary outcome measure was the relationship between length of stay and the Modified Frailty Index. There were 464 ≤3 day and 388 >3 day patients. The groups were similar in demographics and comorbidities. There were significant differences in the Modified Frailty Index (p < 0.01), operative time (p < 0.01), postoperative complications (p < 0.01), 30-day readmissions (p = 0.03), and 30-day reoperation rate (p < 0.01). Significantly more patients were discharged home in the ≤3 day cohort. Correspondence analysis demonstrated a higher Modified Frailty Index was indicative of longer length of stay. A Modified Frailty Index of 0 was strongly related to a length of stay 0 to 3 days, and a Modified Frailty Index of 2 was strongly related to a 8- to 14-day stay. This was a single-center study performed on a retrospective data set. Patients undergoing elective colorectal surgery with a higher Modified Frailty Index were more likely not to attain early discharge. Despite similar demographics, the Modified Frailty Index could discriminate between patient outcomes, and correlated with longer operating times, length of stay, and readmissions. By using a prospective score to identify patients at risk for not achieving early discharge preoperatively, resources and postoperative support can be better allocated.
    Diseases of the Colon & Rectum 03/2014; 57(3):337-42. · 3.34 Impact Factor
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    ABSTRACT: The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes. Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach. Overall, 294 patients were analyzed-116 LAP (39.5 %), 153 OPEN (52.0 %), and 25 (8.5 %) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1-20) LAP, 6 days (range 3-13) CONVERTED, and 8 days (range 1-35) OPEN (p < 0.01). More OPEN had postoperative complications (p < 0.01)-complication rates were 43.8 % OPEN, 32.0 % CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6 % OPEN, 16.0 % CONVERTED, 12.1 % LAP). Overall 3-year disease-free survival (DFS) was 98.3 %, and local recurrence rate was 2.0 %. By approach, DFS was 100 % CONVERTED, 93.1 % LAP, and 87.6 % OPEN (p = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1 % LAP, and 97.4 %. OPEN. Local recurrence was 0 % CONVERTED, 2 % OPEN, and 2.6 % LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (p = 0.05), with comparable local recurrence (p = 0.07) and OS rates (0.43). LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.
    Surgical Endoscopy 02/2014; · 3.43 Impact Factor
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    ABSTRACT: This video demonstrates a laparoscopic abdominal perineal resection for a fixed 4.8-cm mass involving the posterior and left rectal walls and left puborectalis, 2 cm from the anal verge (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A127). We detail the steps of the procedure, all completed in lithotomy, including lateral-to-medial dissection; identification and protection of the left ureter and presacral nerves; division of the inferior mesenteric artery; medial-to-lateral dissection, with meeting the previous dissection plane; total mesorectal excision and pelvic dissection; perineal dissection and layered closure; and abdominal inspection and colostomy creation. Total operative time was 181 minutes. The specimen total mesorectal excision was complete with a negative circumferential radial margin (greater than 1 cm). Final pathology was T3N2M0.
    Diseases of the Colon & Rectum 02/2014; 57(2):251. · 3.34 Impact Factor
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    ABSTRACT: After more than a decade of improvement, our enhanced recovery pathway had patients who had undergone laparoscopic colectomy going home a mean 3.7 days postoperatively. We wondered if adding a transverse abdominus plane block and intravenous acetaminophen to an established pathway would improve outcomes and resource use. The aim of this study was to evaluate the impact of modification of an enhanced recovery pathway on patient outcomes. This was a case-matched study. After the addition of transverse abdominus plane blocks and acetaminophen to the enhanced recovery pathway 12 months ago, review of a prospective database was performed. Patients were matched by procedure type, age, and sex. This study was performed at a tertiary referral center. Patients undergoing elective major laparoscopic colorectal surgery from 2010 to 2012 were included. The primary outcome measures were hospital length of stay, readmission rate, postoperative complications, and the cost of the hospital episode before and after the amendment of our enhanced recovery pathway. Two hundred eight elective major laparoscopic cases were evaluated. Both groups were similar in demographics and comorbidities. Length of stay was significantly shorter once transverse abdominus plane blocks and acetaminophen were introduced (p < 0.01), dropping from 3.7 to 2.6 days. There were significantly more complications in the prechange group (p = 0.02), but no significant differences in readmissions or mortality. Direct costs were similar, but there was a $500 increase in total margin per case (p = 0.004) with the pathway changes. With the use of statistical process control to examine the effect on outliers, there was significantly less variation in the mean length of stay (2.29 vs 1.90 days, p < 0.01) after the addition of transverse abdominus plane blocks and intravenous acetaminophen. The single-surgeon, single-institution design was a limitation of this study. The addition of a transverse abdominus plane block and acetaminophen significantly reduced length of stay more than that seen with a previously established pathway. Statistical process control demonstrated that our pathway changes significantly reduced the spread of outliers around our mean length of stay.
    Diseases of the Colon & Rectum 02/2014; 57(2):194-200. · 3.34 Impact Factor
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    ABSTRACT: Laparoscopy is increasingly used for rectal cancer surgery. Laparoscopic surgery is not attempted for some suitable patients because of concerns for conversion or technical difficulty. This study aimed to evaluate oncologic and short-term outcomes for patients undergoing curative resection for rectal cancer via laparoscopic and open approaches. A prospective database was reviewed to identify rectal cancer resections from 2005 to 2011. Patients who had primary rectal cancer within 15 cm of the anal verge were included in the study. Those with recurrent or metastatic disease were excluded. Patients were assigned to laparoscopic or open approaches preoperatively based on clinical criteria and imaging. All patients underwent a standard total mesorectal excision and followed a standardized enhanced recovery pathway. The oncologic and clinical outcomes were evaluated by approach. The analysis included 81 patients. The preoperative assignments consisted of 62 laparoscopic (77 %) and 19 open (23 %) procedures. Nine laparoscopic procedures (14.5 %) were converted to open procedures. After a median follow-up period of 25 months, all oncologic outcomes were comparable. Three patients (two laparoscopic, one open) had a positive circumferential margin (≤1 mm). The laparoscopic and open groups were similar in terms of their 3-year disease-free periods (93.6 vs. 88.2 %; P = 0.450) and overall survival periods (93.5 vs. 90.9 %; P = 0.766). The local recurrence rate was 2.5 %. Laparoscopic resection for rectal cancer can be attempted for most patients. Conversion to open procedure does not compromise clinical or oncologic outcomes. In practice, combining laparoscopic and open surgery optimizes resource use and results in at least equivalent outcomes.
    Surgical Endoscopy 02/2014; · 3.43 Impact Factor
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    ABSTRACT: Virtual reality simulation for laparoscopic colectomy has been used for training of surgical residents and has been considered as a model for technical skills assessment of board-eligible colorectal surgeons. However, construct validity (the ability to distinguish between skill levels) must be confirmed before widespread implementation. This study was designed to specifically determine which metrics for laparoscopic sigmoid colectomy have evidence of construct validity. General surgeons that had performed fewer than 30 laparoscopic colon resections and laparoscopic colorectal experts (>200 laparoscopic colon resections) performed laparoscopic sigmoid colectomy on the LAP Mentor model. All participants received a 15-minute instructional warm-up and had never used the simulator before the study. Performance was then compared between each group for 21 metrics (procedural, 14; intraoperative errors, 7) to determine specifically which measurements demonstrate construct validity. Performance was compared with the Mann-Whitney U-test (p < 0.05 was significant). Fifty-three surgeons; 29 general surgeons, and 24 colorectal surgeons enrolled in the study. The virtual reality simulators for laparoscopic sigmoid colectomy demonstrated construct validity for 8 of 14 procedural metrics by distinguishing levels of surgical experience (p < 0.05). The most discriminatory procedural metrics (p < 0.01) favoring experts were reduced instrument path length, accuracy of the peritoneal/medial mobilization, and dissection of the inferior mesenteric artery. Intraoperative errors were not discriminatory for most metrics and favored general surgeons for colonic wall injury (general surgeons, 0.7; colorectal surgeons, 3.5; p = 0.045). Individual variability within the general surgeon and colorectal surgeon groups was not accounted for. The virtual reality simulators for laparoscopic sigmoid colectomy demonstrated construct validity for 8 procedure-specific metrics. However, using virtual reality simulator metrics to detect intraoperative errors did not discriminate between groups. If the virtual reality simulator continues to be used for the technical assessment of trainees and board-eligible surgeons, the evaluation of performance should be limited to procedural metrics.
    Diseases of the Colon & Rectum 02/2014; 57(2):210-214. · 3.34 Impact Factor
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    ABSTRACT: Background Factors influencing recurrence of ileocecal Crohn’s disease (CD) after surgical resection may differ between adolescents and adults. Methods Crohn’s disease patients who underwent ileocecectomy were retrospectively divided into pediatric onset (age at diagnosis ≤16, n=34) and adult onset (>16, n=108) patients to evaluate differences in risks of endoscopic and clinical recurrence. Results In 142 patients, rates of any recurrence, endoscopic and clinical recurrence at 5 years were 78%, 88% and 65%, respectively. Risks of recurrence were similar between groups. Younger patients were more likely to be on immunologics preoperatively and more likely to be started on immunoprophylaxis postoperatively. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in the older group. Conclusion Despite increased preoperative and postoperative immunoprophylaxis in younger patients, recurrence rates of CD after ileocecectomy do not differ between these groups. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in patients with adult onset CD..
    The American Journal of Surgery. 01/2014;
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    ABSTRACT: Background Our objective was to evaluate ileostomy reversal patients managed with a standardized Enhanced Recovery Pathway to identify factors associated with readmissions. Methods Prospective review database identified ileostomy reversal patients. Variables for the index admission and readmission were evaluated. Results 332 patients were analyzed. The primary diagnosis was colorectal cancer (57.6%). 13% were discharged by postoperative day (POD) 1, 47% by POD2, and 65% by POD3. The complication rate was 16.8%. The main complication was ileus/small bowel obstruction (n=27). 30-day readmission rate was 12.4% (n=41); small bowel obstruction (n=27) was the most frequent readmission diagnosis. The median readmission POD was 7. Only 1 patient had a follow-up visit prior to readmission. The median readmission length of stay was 4 days. Conclusions Most ileostomy reversals readmissions occur before the first follow-up and stem from preventable causes. An Enhanced Recovery Pathway modification may improve outcomes and utilization in this group. Classifications Ileostomy, Enhanced Recovery Pathways, Patient Outcomes, Readmission Rates, Colorectal Surgery
    The American Journal of Surgery. 01/2014;
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    ABSTRACT: Background Quality improvement in colorectal surgery (CRS) requires implementation of tools to improve patient and financial outcomes, and assessment of results. Our objective was to evaluate the durability of transversus abdominis plane (TAP) blocks and a standardized enhanced recovery protocol (ERP) on a large series of laparoscopic colorectal resections. Study Design 200 consecutive laparoscopic CRS patients received TAP blocks under laparoscopic guidance at the end of their operation. All were managed with a standardized ERP. Demographic, perioperative, and postoperative outcome variables were analyzed. The main outcome measures were length of stay (LOS), readmission, reoperation, morbidity, and mortality rates. Results Of 200 cases, 194 were elective and 6 emergent. The main diagnosis was colorectal cancer (45%). The mean age was 61.2 years, mean BMI was 29.2 kg/m2, and the majority (63%) were ASA class III. The main procedure performed was a segmental colectomy (64%). Mean operative time was 181 minutes. Nine cases (4.5%) were converted to open. The median LOS was 2 days (range, 1-8). 21% were discharged by postoperative day (POD) 1, 41% by POD2, and 77% by POD3. By POD7, 99% were discharged. 12% (n=24) had complications, and 6.5% (n=13) were readmitted. There were 3 unplanned reoperations and no mortalities. Comparing the first and second groups of 100 consecutive patients further tested the consistency of the TAP block benefit. With comparable demographics, there were no significant differences in readmission, complication, or reoperation rates over the entire series. Conclusions Adding TAP blocks to a ERP facilitated shorter LOS with low readmission and reoperation rates when compared to previously published series. The effect appears durable and consistent in a large case series. TAP blocks may be an efficient, cost-effective method for improving laparoscopic CRS results.
    Journal of the American College of Surgeons 01/2014; · 4.50 Impact Factor
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    ABSTRACT: The surgical indications for symptomatic rectocele are undefined, and surgery has high recurrence rates. We implemented magnetic resonance imaging defecography (MRID) to determine if utilizing strict inclusion criteria for rectocele repair improves outcomes. Patients with obstructive defecation syndrome (ODS) who underwent dynamic MRID were evaluated. Indications for surgical repair were defecation requiring manual assistance and the following MRID results: anterior defect >2 cm, incomplete evacuation, and the absence of perineal descent. Primary outcomes were the change in quality of life (QOL) scores and recurrence. From 2006 to 2013, 143 patients who presented with ODS underwent MRID. Seventeen patients met the criteria for repair. Recurrence was low (5.8%) with a median follow-up of 23 months, QOL scores improved from 57.3 to 76.5 (P = .041). A minority of patients (12%) with ODS met the above criteria for rectocele repair. Patients who underwent repair had a significant improvement in QOL and low recurrence rate.
    American journal of surgery 12/2013; · 2.36 Impact Factor
  • Surgical Endoscopy 12/2013; · 3.43 Impact Factor

Publication Stats

5k Citations
853.28 Total Impact Points

Institutions

  • 2006–2014
    • Case Western Reserve University
      • • Law-Medicine Center
      • • University Hospitals Case Medical Center
      • • Division of Colorectal Surgery
      Cleveland, Ohio, United States
    • Medical University of Ohio at Toledo
      • Department of Surgery
      Toledo, Ohio, United States
  • 2013
    • St. Olavs Hospital
      Nidaros, Sør-Trøndelag, Norway
    • University of Southern California
      Los Angeles, California, United States
    • Vanderbilt University
      Nashville, Michigan, United States
  • 2005–2013
    • Case Western Reserve University School of Medicine
      • Department of Surgery
      Cleveland, OH, United States
  • 2012
    • Norwegian Centre for Integrated Care and Telemedicine
      Tromsø, Troms, Norway
  • 2011
    • University Hospitals
      • Case Medical Center
      Cleveland, OH, United States
  • 2008–2010
    • Medical College of Wisconsin
      • Department of Surgery
      Milwaukee, WI, United States
    • University of Cincinnati
      • Department of Surgery
      Cincinnati, OH, United States
  • 2007–2010
    • Alexandria University
      • Department of Surgery (Faculty of Dentistry)
      Alexandria, Alexandria, Egypt
    • Mayo Foundation for Medical Education and Research
      • Division of Colon and Rectal Surgery
      Scottsdale, AZ, United States
    • Thomas Jefferson University
      • Department of Anesthesiology
      Philadelphia, PA, United States
  • 2006–2010
    • Cleveland State University
      Cleveland, Ohio, United States
  • 2009
    • GlaxoSmithKline plc.
      Londinium, England, United Kingdom
    • University Hospital of North Norway
      Tromsø, Troms, Norway
  • 2001–2007
    • Cleveland Clinic
      • Department of Cancer Biology
      Cleveland, Ohio, United States
  • 2004
    • University of Hull
      Kingston upon Hull, England, United Kingdom