Brian S Diggs

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

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Publications (110)508.46 Total impact

  • Journal of the American College of Surgeons 10/2015; 221(4):S135. DOI:10.1016/j.jamcollsurg.2015.07.318 · 5.12 Impact Factor
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    ABSTRACT: A reliable method to identify pathologic complete responders (pCR) or non-responders (NR) to neoadjuvant chemoradiation therapy (NAT) would dramatically improve therapy for esophageal cancer. The purpose of this study is to investigate if a distinct profile of prognostic molecular markers can predict pCR after neoadjuvant therapy. Expression of p53, Her-2/neu, Cox-2, Beta-catenin, E-cadherin, MMP-1, NFkB, and TGF-B was measured by immunohistochemistry in pre-treatment biopsy tissue and graded by an experienced pathologist. A pCR was defined as no evidence of malignancy on final pathology. Molecular profiles comparing responders to non-responders were analyzed using classification and regression tree analysis to investigate response to NAT and overall survival. Nineteen patients were pCRs and 34 were NRs. pCRs were more likely to be alive at follow-up than NRs (p < 0.01). Thirty-seven distinct profiles were identified. Expression of molecular markers was highly heterogeneous between patients and did not correlate with a response to NAT, survival (p = 0.47) or clinical stage (p = 0.39) when evaluated either as individual markers or in combination with other expression patterns. NAT dramatically impacts survival through a mechanism independent of known molecular markers of esophageal cancer, which are expressed in a highly heterogeneous fashion and do not predict response to NAT or survival.
    Journal of Gastrointestinal Surgery 09/2015; DOI:10.1007/s11605-015-2944-7 · 2.80 Impact Factor
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    ABSTRACT: Bile duct injury (BDI) after laparoscopic cholecystectomy (LC) has significant cost impact and is a significant source of morbidity and mortality. We undertook a population-based assessment of the national experience with BDI between 2001 and 2011 and compared this to our report for the prior decade. Using the nationwide inpatient sample (NIS) for 2001-2011, we identified patients who underwent LC or partial cholecystectomy, with and without biliary reconstruction. Data were analyzed using methods that accounted for the hierarchical, stratified random sampling of the NIS. Both univariate modeling and multivariate modeling were performed. LCs increased from 71.1 % in 2001 to 79.0 % in 2011 (p < 0.0001). Annual mortality decreased from 0.56 to 0.38 % (p = 0.002). In 2001, 0.11 % of LCs were associated with biliary reconstruction versus 0.09 % in 2011 (p = 0.15) with rates ranging from 0.08 to 0.12 %. The need for reconstruction was associated with an average in-hospital mortality rate of 4.4 %. Mortality rates from LC remained consistent across the study period (average mortality, 0.10 %, p = 0.57). Under multivariate analysis, admission to rural or urban non-teaching centers was associated with a decreased rate of injury; the majority of major BDIs were admitted from clinic or outpatient settings. These results are consistent with results from the prior decade. Neither emergent admission nor race was associated with increased odds of BDI, and this differs from our prior analysis. LC continued to increase in utilization between 2001 and 2011. Although rates of BDI have decreased, the need for reconstruction continues to be associated with a significant mortality. In addition, mortality related to biliary reconstruction is also higher than previously published series and may reflect the complexity of managing biliary injury as well as the higher likelihood of these patients having comorbid conditions.
    Surgical Endoscopy 08/2015; DOI:10.1007/s00464-015-4469-2 · 3.26 Impact Factor
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    ABSTRACT: The purpose of this study was to evaluate the effects of neoadjuvant therapy on lymph node harvest (LNH), lymph node ratio (LNR), and overall survival rates after esophagectomy. A retrospective analysis of 111 patients who underwent esophagectomy for esophageal adenocarcinoma from 2001 to 2010 was performed. Patients were divided into two groups: neoadjuvant chemoradiotherapy prior to surgery (NEOSURG) versus surgery alone (SURG). There were 83 patients (75 %) in the NEOSURG group and 28 (25 %) in the SURG group with a mean age of 66 and 67 years, respectively. The median LNH in the NEOSURG group and SURG group was 16.0 and 15.5, respectively (p = 0.57). Within the NEOSURG group, the median LNH was 16 for complete responders, 14 for partial responders, 16 for nonresponders, and 18 in those who were pathologically upstaged (p = 0.434). The median LNR was 0, 0, 0.1, and 0.2, respectively (p < 0.001). Complete response after neoadjuvant therapy demonstrated a trend toward improved survival (p = 0.056). The LNH was not significantly influenced by neoadjuvant treatment or pathologic response. The LNR was inversely related to pathologic response after neoadjuvant therapy. Complete pathologic response to neoadjuvant therapy trends to improve survival rates.
    Journal of Gastrointestinal Surgery 04/2015; 19(7). DOI:10.1007/s11605-015-2821-4 · 2.80 Impact Factor
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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 · 1.78 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; 209(5). DOI:10.1016/j.amjsurg.2015.01.003 · 2.29 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; 25(7):1-9. DOI:10.1017/S1047951114002583 · 0.84 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 · 3.75 Impact Factor
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    ABSTRACT: Background & 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. Methods: We screened 696 patients with troublesome regurgitation despite daily PPI use with 3 validated GERD-specific symptom scales, on and off PPIs. Those with at least troublesome regurgitation (based on the Montreal definition) on PPIs underwent barium swallow, esophagogastroduodenoscopy, 48-hour esophageal pH monitoring (off PPIs), and high-resolution esophageal manometry analyses. Patients with GERD and hiatal hernias ≤2 cm were randomly assigned to groups that underwent TF and then received 6 months of placebo (n = 87), or sham surgery and 6 months of once- or twice-daily omeprazole (controls, n = 42). Patients were blinded to therapy during follow-up period and reassessed at 2, 12, and 26 weeks. At 6 months, patients underwent 48-hour esophageal pH monitoring and esophagogastroduodenoscopy. Results: By intention-to-treat analysis, TF eliminated troublesome regurgitation in a larger proportion of patients (67%) than PPIs (45%) (P = .023). A larger proportion of controls had no response at 3 months (36%) than subjects that received TF (11%; P = .004). Control of esophageal pH improved after TF (mean 9.3% before and 6.3% after; P < .001), but not after sham surgery (mean 8.6% before and 8.9% after). Subjects from both groups who completed the protocol had similar reductions in GERD symptom scores. Severe complications were rare (3 subjects receiving TF and 1 receiving the sham surgery). Conclusions: TF was an effective treatment for patients with GERD symptoms, particularly in those with persistent regurgitation despite PPI therapy, based on evaluation 6 months after the procedure. no: NCT01136980.
    Gastroenterology 10/2014; 148(2). DOI:10.1053/j.gastro.2014.10.009 · 16.72 Impact Factor

  • Journal of the American College of Surgeons 10/2014; 219(4):e128. DOI:10.1016/j.jamcollsurg.2014.07.727 · 5.12 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 · 2.99 Impact Factor

  • Journal of the American College of Surgeons 09/2014; 219(3):S45-S46. DOI:10.1016/j.jamcollsurg.2014.07.102 · 5.12 Impact Factor

  • Journal of the American College of Surgeons 09/2014; 219(3):S95. DOI:10.1016/j.jamcollsurg.2014.07.227 · 5.12 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 · 2.74 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; 209(2). DOI:10.1016/j.amjsurg.2014.06.013 · 2.29 Impact Factor
  • Erin W. Gilbert · Brian S. Diggs · Brett C. Sheppard ·

    Gastroenterology 05/2014; 146(5):S-1068. DOI:10.1016/S0016-5085(14)63896-8 · 16.72 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 · 16.72 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 · 5.12 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 Cancer 2013;. © 2013 American Cancer Society.
    Cancer 02/2014; 120(4). DOI:10.1002/cncr.28447 · 4.89 Impact Factor

Publication Stats

2k Citations
508.46 Total Impact Points


  • 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
  • 2012
    • 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
  • 2008
    • University of Toronto
      Toronto, Ontario, Canada
    • Portland State University
      • Department of Sociology
      Portland, OR, United States
    • University of Michigan
      • Department of Cardiac Surgery
      Ann Arbor, MI, United States
  • 2006
    • Portland VA Medical Center
      Portland, Oregon, United States