Brian S Diggs

Oregon Health and Science University, Portland, Oregon, United States

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Publications (100)423.93 Total impact

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    ABSTRACT: This study aimed to determine the impact of preoperative staging on the treatment of clinical T2N0 (cT2N0) esophageal cancer patients undergoing esophagectomy. We reviewed a retrospective cohort of 27 patients treated at a single institution between 1999 and 2011. Clinical staging was performed with computed tomography, positron emission tomography, and endoscopic ultrasound. Patients were separated into two groups: neoadjuvant therapy followed by surgery (NEOSURG) and surgery alone (SURG). There were 11 patients (41%) in the NEOSURG group and 16 patients (59%) in the SURG group. In the NEOSURG group, three of 11 patients (27%) had a pathological complete response and eight (73%) were partial or nonresponders after neoadjuvant therapy. In the SURG group, nine of 16 patients (56%) were understaged, 6 (38%) were overstaged, and 1 (6%) was correctly staged. In the entire cohort, despite being clinically node negative, 14 of 27 patients (52%) had node-positive disease (5/11 [45%] in the NEOSURG group, and 9/16 [56%] in the SURG group). Overall survival rate was not statistically significant between the two groups (P = 0.96). Many cT2N0 patients are clinically understaged and show no preoperative evidence of node-positive disease. Consequently, neoadjuvant therapy may have a beneficial role in treatment. © 2015 International Society for Diseases of the Esophagus.
    Diseases of the Esophagus 03/2015; DOI:10.1111/dote.12334 · 2.06 Impact Factor
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    ABSTRACT: Our objective was to determine if cholecystectomy for biliary dyskinesia (BD) was performed more commonly in the United States than in 4 comparator countries around the world. Using the Nationwide Inpatient Sample, we extracted and analyzed data for cholecystectomy from 1991 to 2011 using ICD-9 (International Classification of Diseases 9th Revision) procedure codes. To derive the number of cholecystectomies performed for BD, we used the ICD-9 code 575.8, greater than 80% of which are patients with BD. The same or equivalent code was used for the international comparator group. Through a SURGINET query we obtained data from verifiable national databases in 4 developed countries including the Swedish quality registry for surgical treatments of gallstone-related conditions (GallRiks), the Norwegian Cholecystectomy Registry, the Australian Bureau of Statistics, and the Polish National Health Insurance Agency. In the years ranging from 2008 to 2011, the number of cholecystectomies for BD per 1,000,000 population per year was less than 25 in the 4 comparator countries and greater than 85 in the United States (P < .01). From 1991 to 2011, the number of cholecystectomies for BD in the United States significantly increased from 43.3 to 89.1 per 1,000,000 population (P < .01). These data strongly suggest that cholecystectomy for BD is over utilized in the United States. In addition, this trend continues to increase in frequency. Copyright © 2015 Elsevier Inc. All rights reserved.
    The American Journal of Surgery 02/2015; DOI:10.1016/j.amjsurg.2015.01.003 · 2.41 Impact Factor
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    ABSTRACT: To quantify myocardial blood flow in infants and children with mild or moderate aortic stenosis using adenosine-infusion cardiac magnetic resonance. It is unclear whether asymptomatic children with mild/moderate aortic stenosis have myocardial abnormalities. In addition, cardiac magnetic resonance-determined normative myocardial blood flow data in children have not been reported. We studied 31 infants and children with either haemodynamically normal hearts (n=20, controls) or mild/moderate aortic stenosis (n=11). The left ventricular myocardium was divided into six segments, and the change in average segmental signal intensity during contrast transit was used to quantify absolute flow (ml/g/minute) at rest and during adenosine infusion by deconvolution of the tissue curves with the arterial input of contrast. In all the cases, adenosine was well tolerated without complications. The mean pressure gradient between the left ventricle and the ascending aorta was higher in the aortic stenosis group compared with controls (24 versus 3 mmHg, p<0.001). Left ventricular wall mass was slightly higher in the aortic stenosis group compared with controls (65 versus 50 g/m2, p<0.05). After adenosine treatment, both the absolute increase in myocardial blood flow (p<0.0001) and the hyperaemic flow significantly decreased (p<0.001) in children with mild/moderate aortic stenosis compared with controls. Abnormal myocardial blood flow in children with mild/moderate aortic stenosis may be an important therapeutic target.
    Cardiology in the Young 02/2015; DOI:10.1017/S1047951114002583 · 0.86 Impact Factor
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    ABSTRACT: The initial minimum operation for ulcerative colitis is a total abdominal colectomy. Healthy patients may undergo proctectomy at the same time; however, for ill patients, proctectomy is delayed. Since the introduction of biologic medications in 2005, ulcerative colitis medical management has changed dramatically.
    Diseases of the Colon & Rectum 12/2014; 57(12):1358-1363. DOI:10.1097/DCR.0000000000000236 · 3.20 Impact Factor
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    ABSTRACT: & Aims: Transoral esophagogastric fundoplication (TF) can decrease or eliminate features of gastroesophageal reflux disease (GERD) in some patients whose symptoms persist despite proton pump inhibitor (PPI) therapy. We performed a prospective, sham-controlled trial to determine if TF reduced troublesome regurgitation to a greater extent than PPIs in patients with GERD.
    Gastroenterology 10/2014; 148(2). DOI:10.1053/j.gastro.2014.10.009 · 13.93 Impact Factor
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    ABSTRACT: Objective: Cranial vault remodeling for repair of craniosynostosis is associated with significant blood loss and need for blood transfusion. To reduce these events, our institution began using Tranexamic Acid (TXA) peri-operatively in 2012. We sought to quantify the impact TXA has had on reducing blood loss and the transfusion of all blood product components. Methods: With institutional review board approval, a retrospective study from 2006 to 2013 was performed for all patients undergoing surgical correction of craniosynostosis at our institution. All available records were reviewed, and patient data were collected from the time of preoperative evaluation until discharge. We focused our review on patients with non-syndromic single-suture synostosis, before and after the implementation of TXA into our program. Results: We identified a total of 220 patients with craniosynostosis, of which 176 had non-syndromic single-suture disease. Of these 176, a total of 48 received TXA. A single surgical team performed all operations. Median age at time of surgery was 9.1 months (IQR of 5.9-10.4 months). The TXA group had a significant reduction in estimated blood loss (29 vs. 37 ml/kg p<0.01), cell saver volume (46 vs. 83 ml p<0.01), red cell transfusion (33 vs. 42 ml/kg p<0.01), and exposure to plasma/cryoprecipitate transfusion (2% vs. 31% p<0.01). Reduction in platelet transfusion did not reach significance (2% vs. 9% p=0.18). Even with reduced red cell transfusion, the TXA-treated patients exhibited similar post-operative hematocrits to those not treated with TXA(30.1 vs. 30.9% p=0.508). We found that length of stay was reduced with the use of TXA (4 days IQR 3-4 vs. 4 days IQR 4-5, p<0.01), as was output from surgically placed drains (177 vs. 328 ml p<0.01). We found no difference in mortality or post-operative complications between groups. Conclusions: The introduction of TXA for non-syndromic single-suture synostosis repair at our institution resulted in significant reductions in blood loss and use of blood products. Postoperative hematocrits remained the same even with less red cell transfusion. TXA use nearly eliminated the need for plasma transfusion, and is associated with a shorter hospital stay. No difference in postoperative complications was observed. Our data provides further support for the continued use of TXA in our program and its wider acceptance for pediatric cranial vault remodeling.
    Plastic &amp Reconstructive Surgery 10/2014; 134(4S-1 Suppl):22. DOI:10.1097/01.prs.0000455342.16278.23 · 3.33 Impact Factor
  • Journal of the American College of Surgeons 09/2014; 219(3):S95. DOI:10.1016/j.jamcollsurg.2014.07.227 · 4.45 Impact Factor
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    ABSTRACT: Coagulopathy following trauma is associated with poor outcomes. Traumatic brain injury has been associated with coagulopathy out of proportion to other body regions. We hypothesized that injury severity and shock determine coagulopathy independent of body region injured.
    Journal of Trauma and Acute Care Surgery 07/2014; 77(1):67-72. DOI:10.1097/TA.0000000000000255 · 1.97 Impact Factor
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    ABSTRACT: Introduction Merkel cell carcinoma (MCC) is a cutaneous neuroendocrine tumor that may spread via lymphatics and can therefore be staged with sentinel lymph node biopsy (SLNB). MCC is radio- and chemo-sensitive, although the role of adjuvant therapy is still unclear. We examined the impact of different treatments on the outcome of MCC. Methods We performed a retrospective review of state cancer registry data from California, Oregon and Washington of patients diagnosed with primary skin MCC between 1988 and 2012 (n = 4,038). Data was analyzed using Cox-regression and Kaplan-Meier methods to examine disease-specific survival. Results Patients with positive nodes or no documented nodal evaluation had worse survival compared to node negative patients. No nodal evaluation had decreased survival compared to lymph node evaluation by SLNB. Completion lymph node dissection conferred improved survival in patients with a positive SLNB. In clinically node negative patients who had a positive SLNB, radiation and chemotherapy did not affect survival. Conclusions Lymph node evaluation is an important component to MCC treatment. The role of adjuvant radiation and chemotherapy needs further evaluation.
    The American Journal of Surgery 07/2014; DOI:10.1016/j.amjsurg.2014.06.013 · 2.41 Impact Factor
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    ABSTRACT: Background Current quality initiatives call for examination of at least 12 lymph nodes in curative colon cancer resections. The aim of this study was to determine if the number of nodes harvested has increased, and if the increased number nodes correlates with improved staging or overall survival. Study DesignReview of Surveillance, Epidemiology and End Results (SEER) database from 2004-2010 was performed. All patients who underwent colon cancer resection during this date range were analyzed. Number of nodes retrieved, patient stage, overall survival, and overall survival by stage were examined. Multivariable analysis controlled for stage, cancer site, age, year of diagnosis, and number of nodes retrieved. Improved staging was defined as increased detection of stage III patients. Results147,076 patients met inclusion criteria. Median number of nodes analyzed increased sequentially with each year examined, from 12 in 2004 to 17 in 2010. Despite greater number of total nodes obtained and analyzed, there was no increase in the percentage of patients with positive nodes (stage III disease). On multivariable analysis, after controlling for stage, site of disease, age, and year of diagnosis, there was a slight overall survival benefit with increasing nodal retrieval (hazard ratio 0.987 for each additional node removed, 95% CI 0.986-0.988, p<0.001). Conclusions Since quality initiatives have been put in place, there has been an increase in the number of nodes examined in colon cancer resections, but no improvement in staging. The improved survival seen with higher node counts was independent of stage, site of disease, patient age and year of diagnosis.
    Journal of the American College of Surgeons 05/2014; 218(5). DOI:10.1016/j.jamcollsurg.2014.01.039 · 4.45 Impact Factor
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    ABSTRACT: Strictureplasty is an alternative to resection for treatment of Crohn's disease (CD) strictures. It preserves bowel length, and specialized centers report favorable outcomes. Strictureplasty rates, however, are thought to be low, and it was recently removed from required cases for colon and rectal surgery residents. We examined operative characteristics, and trends in its use using a large national database. We examined the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012, identifying patients with CD who underwent strictureplasty. We identified patient characteristics, outcome variables, and trends in utilization of strictureplasty. A total of 9172 patients underwent surgery for CD. Two hundred fifty-six (2.8 %) underwent strictureplasty. Median preoperative albumin was 3.6. Preoperative steroid use and weight loss rates were 39 and 8 %. Rates of wound infection and organ space infection were 11 and 4 %. Rate of reoperation was 6 %. Outcomes did not change significantly over time (all p = NS). The proportion of CD operations that included a strictureplasty decreased from 5.1 to 1.7 % (OR 0.902 with each additional year, 95 % CI (0.852, 0.960), p < 0.001). Strictureplasty as treatment for CD is decreasing in the ACS-NSQIP database. Infectious complications and reoperation rates following strictureplasty are low and have not changed over time.
    Gastroenterology 05/2014; 146(5):S-1030. DOI:10.1016/S0016-5085(14)63754-9 · 13.93 Impact Factor
  • Gastroenterology 05/2014; 146(5):S-1068. DOI:10.1016/S0016-5085(14)63896-8 · 13.93 Impact Factor
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    ABSTRACT: Patients treated with neoadjuvant chemoradiotherapy (NAC) followed by esophagectomy are more likely to have negative margins at resection, be downstaged, and have improved overall survival (OS). The specific aim of this study was to analyze OS outcomes using NAC followed by esophagectomy at a single, tertiary care academic medical center. We retrospectively analyzed 106 patients that underwent NAC with platinum-based chemotherapy plus 5-fluorouracil (5-FU) or capecitabine followed by esophagectomy from September 1996 to May 2011. OS was analyzed by the Kaplan Meier method. Initial staging determined that of 106 patients, 62% had stage III (n=66), 31% stage II (n=33), and 7% had stage I disease (n=7). Following NAC, 92.5% (n=98) were resected with negative (R0) margins and pathologic staging revealed 59% (n=62) were downstaged, 9% (n=10) were upstaged, and 32% (n=34) remained at the same stage. A pathologic complete response (pCR) was achieved in 29% (n=31) of the cohort. Median OS was 35.2 months for all patients, 42 months for downstaged patients, 13 months when upstaged, and 17 months for those who remained at the same stage (P=0.08). OS by histological type was 30 months for adenocarcinoma and 71 months for squamous cell carcinoma (P=0.06). NAC was effective in downstaging 59% of patients and effectively increased the chance for an R0 resection. These patients, in turn, had improved OS compared to the median OS. Patients with squamous cell carcinoma showed a trend towards more favorable OS.
    Journal of gastrointestinal oncology 04/2014; 5(2):86-91. DOI:10.3978/j.issn.2078-6891.2014.014
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    ABSTRACT: The survival impact of neoadjuvant chemoradiotherapy (CRT) on esophageal cancer remains difficult to establish for specific patients. The aim of the current study was to create a Web-based prediction tool providing individualized survival projections based on tumor and treatment data. Patients diagnosed with esophageal cancer between 1997 and 2005 were selected from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The covariates analyzed were sex, T and N classification, histology, total number of lymph nodes examined, and treatment with esophagectomy or CRT followed by esophagectomy. After propensity score weighting, a log-logistic regression model for overall survival was selected based on the Akaike information criterion. A total of 824 patients with esophageal cancer who were treated with esophagectomy or trimodal therapy met the selection criteria. On multivariate analysis, age, sex, T and N classification, number of lymph nodes examined, treatment, and histology were found to be significantly associated with overall survival and were included in the regression analysis. Preoperative staging data and final surgical margin status were not available within the SEER-Medicare data set and therefore were not included. The model predicted that patients with T4 or lymph node disease benefitted from CRT. The internally validated concordance index was 0.72. The SEER-Medicare database of patients with esophageal cancer can be used to produce a survival prediction tool that: 1) serves as a counseling and decision aid to patients and 2) assists in risk modeling. Patients with T4 or lymph node disease appeared to benefit from CRT. This nomogram may underestimate the benefit of CRT due to its variable downstaging effect on pathologic stage. It is available at skynet.ohsu.edu/nomograms. Cancer 2013;. © 2013 American Cancer Society.
    Cancer 02/2014; 120(4). DOI:10.1002/cncr.28447 · 4.90 Impact Factor
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    ABSTRACT: Central line-associated bloodstream infections (CLABSIs) are a significant source of morbidity and mortality. This study sought to determine whether implementation of the Institute for Healthcare Improvement (IHI) Central Line Bundle would reduce the incidence of CLABSIs. The IHI Central Line Bundle was implemented in a surgical intensive care unit. Patient demographics and the rate of CLABSIs per 1,000 catheter days were compared between the pre- and postintervention groups. Contemporaneous infection rates in an adjacent ICU were measured. Baseline demographics were similar between the pre- and postintervention groups. The rate of CLABSIs per catheter days decreased from 19/3,784 to 3/1,870 after implementation of the IHI Bundle (1.60 vs 5.02 CLABSIs per 1,000 catheter days; rate ratio .32 [.08 to .99, P < .05]). There was no significant change in CLABSIs in the control ICU. Implementation of the IHI Central Line Bundle reduced the incidence of CLABSIs in our SICU by 68%, preventing 12 CLABSIs, 2.5 deaths, and saving $198,600 annually.
    American journal of surgery 01/2014; 207(6). DOI:10.1016/j.amjsurg.2013.08.041 · 2.41 Impact Factor
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    ABSTRACT: Preoperative chemotherapy is increasingly utilized in the treatment of colorectal liver metastases (CRLM). Although this strategy may improve resectability, long-term advantages of preoperative chemotherapy for resectable CRLM are less clear. The objective of this study is to report safety and outcomes when perioperative chemotherapy is routinely added to surgery for CRLM. A retrospective review of patients undergoing liver resections for CRLM during 2003-2011 in single academic oncology center. Demographic data, tumor characteristics, chemotherapy, surgical details, complications and survival were analyzed. The study included 157 patients that underwent 168 liver operations. One hundred eighteen patients (70 %) underwent preoperative chemotherapy (75 % oxaliplatin-based). Preoperative portal vein embolization was utilized in 16 (10.1 %) patients. Overall survival (OS) was 89, 57, and 27 % at 1, 3, and 5 years, respectively (median survival-42.8 months). Eleven (7 %) patients had repeat resections for liver recurrence. Thirty-day mortality was 1.26 %, morbidity-24 % (6 %-liver related). Complications were not significantly different in patients that had preoperative chemotherapy. On a multivariate analysis advanced age and >3 lesions predicted poor OS, while advanced age, lesions >5 cm, synchronous lesions, margin-positivity and resection less than hepatectomy were associated with decreased DFS. Our results suggest that even with chemotherapy and resection only a subset of patients remain disease-free after 5 years. However, even in a high-risk patient with multiple lesions, preoperative chemotherapy can be administered safely without apparent increase in postoperative complications. Perioperative chemotherapy should be considered particularly in patients with multifocal or large lesions, synchronous disease and short disease-free interval.
    Journal of Gastrointestinal Surgery 10/2013; 17(12). DOI:10.1007/s11605-013-2295-1 · 2.39 Impact Factor
  • Ilia Gur, Brian S Diggs, Susan L Orloff
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    ABSTRACT: The surgical portosystemic shunts (PSS) are a time-proven modality for treating portal hypertension. Recently, in the era of liver transplantation and the transjugular intrahepatic portosystemic shunts (TIPS), use of the PSS has declined. This study was conducted to evaluate changes in practice, referral patterns, and short- and longterm outcomes of the use of the surgical PSS before and after the introduction of the Model for End-stage Liver Disease (MELD). A retrospective analysis of 47 patients undergoing PSS between 1996 and 2011 in a single university hospital was conducted. Subgroups of patients with cirrhosis (53%), Budd-Chiari syndrome (13%), portal vein thrombosis (PVT) (26%), and other pathologies (9%) differed significantly with respect to shunt type, Child-Pugh class, MELD score and perioperative mortality. Perioperative mortality at 60 days was 15%. Five-year survival was 68% (median: 70 months); 5-year shunt patency was 97%. Survival was best in patients with PVT and worst in those with Budd-Chiari syndrome compared to other subgroups. Patency was better in the subgroups of patients with cirrhosis and other pathologies compared with the PVT subgroup. Substantial changes in referral patterns coincided with the adoption of the MELD in 2002, with decreases in the incidence of cirrhosis and variceal bleeding, and increases in non-cirrhotics and hypercoagulopathy. Although the spectrum of diseases benefiting from surgical PSS has changed, surgical shunts continue to constitute an important addition to the surgical armamentarium. Selected subgroups with variceal bleeding in well-compensated cirrhosis and PVT benefit from the excellent longterm patency offered by the surgical PSS.
    HPB 08/2013; DOI:10.1111/hpb.12163 · 2.05 Impact Factor
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    ABSTRACT: The aim of this study was to examine the impact of the Charlson Comorbidity Index-Grade (CCI-G) on predicting outcomes and overall survival after open and minimally invasive esophagectomy (MIE). One hundred and forty-six patients who underwent esophagectomy between 1995 and 2011 for stage II and III cancer were selected and separated into open esophagectomy (Open) and MIE groups. Risk adjustment was performed using the CCI-G. The outcomes of interest were operative time, estimated blood loss (EBL), lymph node harvest, length of hospital stay (LOS), major complications, 30-day mortality, and overall survival. Sixty-four patients (44 %) underwent Open while 71 (49 %) had MIE. An additional (7 %) were converted and classified with MIE. There was no significant difference between MIE and Open in terms of operative time. MIE had less EBL (mean difference = 234 mL, p < 0.001), higher lymph node harvest (mean = 7.4 nodes, p < 0.001), and shorter LOS (median = 1.5 days, p = 0.02). Atrial arrhythmias were the most frequent complication, occurring in 33 % of patients in both the MIE and the Open group (p = 0.988). Thirty-day mortality was 2 % for MIE and 5 % for Open (p = 0.459). Five-year survival was 41 % for MIE and 33 % for Open (p = 0.513). Operative approach, age, gender, BMI, clinical stage, and neoadjuvant therapy did not have any significant effect on the outcomes or overall survival. CCI-G influenced outcomes with operative time, LOS, cardiovascular complication, and anastomotic leak rate, favoring CCI-G 0 compared to CCI-G 3. Overall survival was worse for CCI-G 1 in comparison with CCI-G 0 [hazard ratio (HR) 1.99, p = 0.027]. MIE is a safe alternative to open esophagectomy for the treatment of locally advanced esophageal cancer. The presence of comorbidities increased operative time, length of hospital stay, and postoperative complications while worsening overall survival.
    Surgical Endoscopy 07/2013; 27(11). DOI:10.1007/s00464-013-3066-5 · 3.31 Impact Factor
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    ABSTRACT: Gallbladder cancer (GBC) carries an unfavorable prognosis with high mortality. This retrospective study was conducted to identify prognostic factors after resection of GBC, to assist in selecting appropriate surgical and adjuvant therapy. Sixty-two patients from two institutions were identified with GBC by pathology. In 25, the cancer was unresectable at presentation. The remaining 37 patients comprised the study population. Log-rank analysis was used to assess univariate association with disease-free survival (DFS) and disease-specific survival (DSS). Cox regression was used for multivariate analysis. Median DFS and DSS were 22.6 and 28.5 months respectively, with a median follow-up of 44.2 months. On univariate analysis, bile duct (BD) involvement was significantly associated with decreased DFS (P ≤ .001) and DSS (P = .004). BD involvement was uniformly fatal. LN involvement was not significantly associated with DFS or DSS (P = .85, P = .54). All patients with BD involvement in our population died of the disease. The subset of patients with resectable GBC and BD involvement is a group that is at high risk for recurrence and should be treated as such. In our small population, preoperative and intraoperative methods evaluating BD involvement were unreliable.
    Gastrointestinal cancer research: GCR 07/2013; 6(4):101-5.
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    ABSTRACT: BACKGROUND: Determining the molecular profile of colon and rectal cancers offers the possibility of personalized cancer treatment. The purpose of this study was to determine whether known genetic mutations associated with colorectal carcinogenesis differ between colon and rectal cancers and whether they are associated with survival. METHODS: The Oregon Colorectal Cancer Registry is a prospectively maintained, institutional review board-approved tissue repository with associated demographic and clinical information. The registry was queried for any patient with molecular analysis paired with clinical data. Patient demographics, tumor characteristics, microsatellite instability status, and mutational analysis for p53, AKT, BRAF, KRAS, MET, NRAS, and PIK3CA were analyzed. Categorical variables were compared using chi-square tests. Continuous variables between groups were analyzed using Mann-Whitney U tests. Kaplan-Meier analysis was used for survival studies. Comparisons of survival were made using log-rank tests. RESULTS: The registry included 370 patients: 69% with colon cancer and 31% with rectal cancer. Eighty percent of colon cancers and 68% of rectal cancers were stages III and IV. Mutational analysis found no significant differences in detected mutations between colon and rectal cancers, except that there were significantly more BRAF mutations in colon cancers compared with rectal cancers (10% vs 0%, P < .008). No differences were seen in 5-year survival rates of patients with colon versus rectal cancers when stratified by the presence of KRAS, PIK3CA, and BRAF mutations. CONCLUSIONS: Stage III and IV colon and rectal cancers share similar molecular profiles, except that there were significantly more BRAF mutations in colon cancers compared with rectal cancers.
    American journal of surgery 05/2013; 205(5):608-612. DOI:10.1016/j.amjsurg.2013.01.029 · 2.41 Impact Factor

Publication Stats

1k Citations
423.93 Total Impact Points

Institutions

  • 2005–2015
    • Oregon Health and Science University
      • • Department of Surgery
      • • Division of General Surgery
      • • Division of Cardiothoracic Surgery
      • • Digestive Health Center
      Portland, Oregon, United States
  • 2008–2014
    • University of Portland
      Portland, Oregon, United States
    • University of Toronto
      Toronto, Ontario, Canada
    • University of Michigan
      • Department of Cardiac Surgery
      Ann Arbor, MI, United States
    • Portland State University
      • Department of Sociology
      Portland, OR, United States
  • 2012
    • Jefferson College
      Хиллсборо, Missouri, United States
    • University of California, San Francisco
      • Division of Pediatric Cardiothoracic Surgery
      San Francisco, CA, United States
  • 2011
    • Legacy Health
      Portland, Oregon, United States
    • Sanjay Gandhi Post Graduate Institute of Medical Sciences
      • Department of Surgical Gastroenterology
      Lucknow, Uttar Pradesh, India
  • 2010
    • Case Western Reserve University
      Cleveland, Ohio, United States
  • 2006
    • Portland VA Medical Center
      Portland, Oregon, United States