Ryan S Turley

Duke University, Durham, North Carolina, United States

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Publications (46)161.14 Total impact

  • [show abstract] [hide abstract]
    ABSTRACT: Aortic thrombus in the absence of atherosclerotic plaque or aneurysm is rare, and its optimal management remains unclear. Although atypical aortic thrombus (AAT) has been historically managed operatively, successful non-operative strategies have been recently reported. Here, we report our experience in treating patients with AAT that has evolved from a primarily operative approach to a first-line, non-operative strategy. Records of patients treated for AAT between 2008 and 2011 at our institution were reviewed. Ten female and three male patients with ages ranging from 27 to 69 were identified. Seven were treated operatively and six non-operatively. Initial presentation was variable and included limb thromboembolic events (n=6), visceral ischemia (n=5), and stroke (n=1). Associated risk factors included hypercoagulability (76%; n=10,) and hyperlipidemia (38%, n=5). In the non-operative group, complete thrombus resolution was obtained via anticoagulation (n=5) or systemic thrombolysis (n=1). Complete thrombus extraction was achieved in all operative patients, There were 11 significant complications in 5 of the 7 patients (71%) in the operative group; including intraoperative lower extremity embolism, pericardial effusion, stroke, and one death. There was one complication in the patients treated non-operatively. The median hospital length of stay was 9 days (range 3-49) for those treated non-operatively and 30 ( days (range 4-115) for those undergoing operative thrombectomy. Although AAT has traditionally been treated operatively, non-operative management of AAT with anticoagulation or thrombolysis is feasible in selected patients and may lessen morbidity and length of hospitalization in those patients for whom it is appropriate.
    Annals of Vascular Surgery 04/2014; · 0.99 Impact Factor
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    ABSTRACT: We investigate the mechanism through which N-cadherin disruption alters the effectiveness of regional chemotherapy for locally advanced melanoma. N-cadherin antagonism during regional chemotherapy has demonstrated variable treatment effects. Isolated limb infusion (ILI) with melphalan (LPAM) or temozolomide (TMZ) was performed on rats bearing melanoma xenografts after systemic administration of the N-cadherin antagonist, ADH-1, or saline. Permeability studies were performed using Evans blue dye as the infusate, and interstitial fluid pressure was measured. Immunohistochemistry of LPAM-DNA adducts and damage was performed as surrogates for LPAM and TMZ delivery. Tumor signaling was studied by Western blotting and reverse-phase protein array analysis. Systemic ADH-1 was associated with increased growth and activation of the PI3K (phosphatidylinositol-3 kinase)-AKT pathway in A375 but not DM443 xenografts. ADH-1 in combination with LPAM ILI improved antitumor responses compared with LPAM alone in both cell lines. Combination of ADH-1 with TMZ ILI did not improve tumor response in A375 tumors. ADH-1 increased vascular permeability without effecting tumor interstitial fluid pressure, leading to increased delivery of LPAM but not TMZ. ADH-1 improved responses to regional LPAM but had variable effects on tumors regionally treated with TMZ. N-cadherin-targeting agents may lead to differential effects on the AKT signaling axis that can augment growth of some tumors. The vascular targeting actions of N-cadherin antagonism may not augment some regionally delivered alkylating agents, leading to a net increase in tumor size with this type of combination treatment strategy.
    Annals of surgery 03/2014; · 7.90 Impact Factor
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    ABSTRACT: Few studies have examined the current status of ureteral stent use or the indications for stenting, particularly in laparoscopic colorectal surgery. This study examines current national trends and predictors of ureteral stenting in patients undergoing major colorectal operations and the subsequent effects on perioperative outcomes. The 2005-2011 National Surgical Quality Improvement participant user files were used to identify patients undergoing laparoscopic segmental colectomy, low anterior resection, or proctectomy. Trends in stent use were assessed across procedure types. To estimate the predictors of stent utilization, a forward-stepwise logistic regression model was used. A 3:1 nearest neighbor propensity match with subsequent multivariable adjustment was then used to estimate the impact of stents. A total of 42,311 cases were identified, of which 1795 (4.2%) underwent ureteral stent placement. Predictors of stent utilization included diverticular disease, need for radical resection (versus segmental colectomy), recent radiotherapy, and more recent calendar year. After adjustment, ureteral stenting appeared to be associated with a small increase in median operative time (44 min) and a trivial increase in length of stay (5.4%, P < 0.001). However, there were no significant differences in morbidity or mortality. We describe the clinical predictors of ureteral stent usage in this patient population and report that while stenting adds to operative time, it is not associated with significantly increased morbidity or mortality after adjusting for diagnosis and comorbidities. Focused institutional studies are necessary in the future to address the utility of ureteral stents in the identification and possible prevention of iatrogenic injury.
    Journal of Surgical Research 02/2014; · 2.02 Impact Factor
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    ABSTRACT: Coronary artery disease (CAD) is often considered a contraindication to hepatectomy despite a lack of data to support this practice. The purpose of this study is to evaluate the impact of CAD on postoperative outcomes in patients undergoing hepatectomy. A total of 1,206 consecutive patients undergoing hepatectomy from August 1995 to June 2009 were included. Propensity matching was performed to identify differences in morbidity and mortality between patients with and without CAD. Subgroup analyses were performed to stratify patients based on the severity of CAD and the interval between coronary intervention and hepatectomy. Of all patients, 138 (11.4 %) had a diagnosis of CAD and were more likely to have a malignant diagnosis and other comorbid conditions including renal insufficiency, COPD, and diabetes. Matched patients with CAD had no significant differences in complication rates, with 2.2 and 5.8 % of CAD patients experiencing a postoperative myocardial infarction or arrhythmia, respectively. Propensity matching failed to identify differences in mortality or morbidity. Subgroup analysis revealed similar rates of mortality and complications regardless of the severity of CAD or the time interval between coronary intervention and hepatectomy. Despite the increased prevalence of major medical comorbidities, selected patients with CAD can safely undergo hepatectomy with acceptable rates of postoperative morbidity and mortality.
    Journal of Gastrointestinal Surgery 01/2014; · 2.36 Impact Factor
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    ABSTRACT: Background Despite the rising incidence of hepatocellular carcinoma (HCC), challenges and controversy persist in optimizing treatment. As recent randomized trials suggest that ablation may have oncologic equivalence compared to resection for early HCC, the relative morbidity of the two approaches is a central issue in treatment decisions. Although excellent contemporary perioperative outcomes have been reported by a few HPB units, it is not clear that they can be replicated in broader practice. Our objective was to help inform this treatment dilemma by defining perioperative outcomes in a broader set of patients as represented in NSQIP-participating institutions. Study Design Mortality and morbidity data were extracted from the 2005-10 NSQIP user files based on CPT (hepatectomy and ablation) and ICD-9 (HCC). Perioperative outcomes were reviewed, and factors associated with morbidity and mortality were identified with multivariable logistic regression. Results 837 (52%) underwent minor hepatectomy, 444 (28%) underwent major hepatectomy, and 323 (20%) underwent surgical ablation.Mortality rates were 3.4% for minor hepatectomy, 3.7% for ablation, and 8.3% for major hepatectomy (p < 0.01). Major complication rates were 21.3% for minor hepatectomy, 9.3% for ablation, and 35.1% for major hepatectomy (p < 0.01). When controlling for confounders, ablation was associated with decreased mortality (AOR 0.20, 95% CI 0.04-0.97, p=0.046) and major complications (AOR 0.34, 95% CI 0.22-0.52, p<0.001). Conclusions Exceedingly high complication rates following major hepatectomy for HCC exist in the broader NSQIP treatment environment. These data strongly support the use of parenchymal-sparing minor resections or ablation over major hepatectomy for early HCC when feasible.
    Journal of the American College of Surgeons 01/2014; · 4.50 Impact Factor
  • Journal of Surgical Research 01/2014; 186(2):496. · 2.02 Impact Factor
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    ABSTRACT: Objective Aortic thrombus in the absence of atherosclerotic plaque or aneurysm is rare, and its optimal management remains unclear. Although atypical aortic thrombus (AAT) has been historically managed operatively, successful non-operative strategies have been recently reported. Here, we report our experience in treating patients with AAT that has evolved from a primarily operative approach to a first-line, non-operative strategy. Methods Records of patients treated for AAT between 2008 and 2011 at our institution were reviewed. Results Ten female and three male patients with ages ranging from 27 to 69 were identified. Seven were treated operatively and six non-operatively. Initial presentation was variable and included limb thromboembolic events (n=6), visceral ischemia (n=5), and stroke (n=1). Associated risk factors included hypercoagulability (76%; n=10,) and hyperlipidemia (38%, n=5). In the non-operative group, complete thrombus resolution was obtained via anticoagulation (n=5) or systemic thrombolysis (n=1). Complete thrombus extraction was achieved in all operative patients, There were 11 significant complications in 5 of the 7 patients (71%) in the operative group; including intraoperative lower extremity embolism, pericardial effusion, stroke, and one death. There was one complication in the patients treated non-operatively. The median hospital length of stay was 9 days (range 3-49) for those treated non-operatively and 30 ( days (range 4-115) for those undergoing operative thrombectomy. Conclusions Although AAT has traditionally been treated operatively, non-operative management of AAT with anticoagulation or thrombolysis is feasible in selected patients and may lessen morbidity and length of hospitalization in those patients for whom it is appropriate.
    Annals of Vascular Surgery 01/2014; · 0.99 Impact Factor
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    ABSTRACT: Although the relationship between psychoactive substance use and injury is known, evidence remains conflicting on the impact of substance use on clinical outcomes after injury. We hypothesized that preinjury substance use would negatively impact clinical outcomes. National Trauma Registry American College of Surgeons identified patients (n = 9793) presenting to Duke Hospital from 2006 to 2010. Logistic regression models assessed potential predictors of receiving substance screening, mortality, length of stay, ventilator requirement, intensive care admission, or emergency department disposition. Forty-seven percent (4607/9793) of patients received blood alcohol screen (BAS) and 31% (3017/9793) received urine drug screen (UDS). Men were more likely to receive both BASs (P < 0.001) and UDSs (P = 0.001) than women after controlling for potential confounders. There was no significant difference between men and women over the legal limit for alcohol (OLLA; 27.2%, 95% confidence interval [CI]: 25.7%-28.8% versus 24.8%, 95% CI: 22.3%-27.5%). Similarly, younger patients more likely received both BASs (P < 0.001) and UDSs (P < 0.001) compared with older patients. The proportion of patients aged ≤45 y OLLA (26.5 %, 95% CI: 24.9%-28.2%) was similar to those aged >45 y OLLA (26.8%, 95% CI: 24.5%-29.3%). After controlling for potential confounders neither alcohol, nor tetrahydrocannabinol, nor cocaine was predictive of mortality, ventilator requirement, length of stay, or emergency department disposition, but a higher alcohol level (P = 0.0174) predicted intensive care admission. Females and those aged >45 y are less likely to receive BASs and UDSs. Differential screening that is biased may place patients at risk for receiving inadequate care.
    Journal of Surgical Research 11/2013; · 2.02 Impact Factor
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    ABSTRACT: Src kinase inhibition has been shown to augment the efficacy of chemotherapy. Dasatinib, a dual Src/Abl kinase inhibitor approved for the treatment of CML, is under investigation as monotherapy for tumors with abnormal Src signaling, such as melanoma. The goal of this study was to determine if Src kinase inhibition using dasatinib could enhance the efficacy of regionally administered melphalan in advanced extremity melanoma. The mutational status of c-kit and patterns of gene expression predictive of dysregulated Src kinase signaling were evaluated in a panel of 26 human melanoma cell lines. The effectiveness of dasatinib was measured by quantifying protein expression and activation of Src kinase, focal adhesion kinase, and Crk-associated substrate (p130(CAS)), in conjunction with in vitro cell viability assays using seven melanoma cell lines. Utilizing a rat model of regional chemotherapy, we evaluated the effectiveness of systemic dasatinib in conjunction with regional melphalan against the human melanoma cell line, DM443, grown as a xenograft. Only the WM3211 cell line harbored a c-kit mutation. Significant correlation was observed between Src-predicted dysregulation by gene expression and sensitivity to dasatinib in vitro. Tumor doubling time for DM443 xenografts treated with systemic dasatinib in combination with regional melphalan (44.8 days) was significantly longer (p = 0.007) than either dasatinib (21.3 days) or melphalan alone (24.7 days). Systemic dasatinib prior to melphalan-based regional chemotherapy markedly improves the efficacy of this alkylating agent in this melanoma xenograft model. Validation of this concept should be considered in the context of a regional therapy clinical trial.
    Annals of Surgical Oncology 11/2013; · 4.12 Impact Factor
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    ABSTRACT: Although pelvic exenteration (PE) remains an important treatment for advanced pelvic malignancies, it has historically been associated with high morbidity and mortality with unclear long-term benefits. The objectives of this study were (1) estimate complication and mortality rates, (2) determine predictors of complications, and (3) estimate overall survival after PE for patients with locally advanced colorectal and bladder tumors. A total of 377 patients were retrospectively identified from the 2005-2010 NSQIP PUF and an additional 1,111 from the 2004-2010 Surveillance Epidemiology and End Results database with T4M0 colorectal or bladder cancers. A logistic regression model was fitted to estimate early morbidity and mortality. The Kaplan-Meier method was used to estimate survival after PE compared to nonoperative management. Fifty-seven percent of patients had a complication, but 30-day mortality was only 2 %. Patients with preoperative dyspnea and higher ASA class had the highest risk of morbidity. PE for the treatment of T4M0 rectal and bladder cancer was associated with significantly improved long-term survival compared to nonoperative therapy. PE is associated with a high complication rate but low 30-day mortality. The results of this study provide strong evidence to support PE as a viable treatment option for locally advanced rectal and bladder malignancies in appropriately selected patients.
    Journal of Gastrointestinal Surgery 11/2013; · 2.36 Impact Factor
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    ABSTRACT: Various predictors of perioperative risk for patients with rectal cancer undergoing radical resection have been well described, but no simple scoring system for surgeons to estimate this risk currently exists. The objective of this study was to develop a system for more accurate preoperative evaluations of competing risks and more informed shared decision-making with patients diagnosed with rectal cancer. The National Surgical Quality Improvement Program-Participant Use Data File for 2005-2011 was used to retrospectively identify patients undergoing radical resection for rectal cancer. A forward-stepwise multivariable logistic regression model was used to create a dynamic scoring system to preoperatively estimate a patient's risk of major complications. A total of 6,847 patients met study inclusion criteria. Thirteen risk factors were identified, and using these predictive variables, a scoring system was derived to stratify major complication risk after radical resection. The risk of a major complication after radical resection for rectal cancer is dependent on multiple preoperative variables. This study provides surgeons with a simple but effective tool for estimating major complication risk in rectal cancer patients prior to radical resection. This risk-stratification score serves as a patient-centered resource for discussing perioperative risks and assisting with the shared decision-making of operative planning.
    Techniques in Coloproctology 10/2013; · 1.54 Impact Factor
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    ABSTRACT: IMPORTANCE Although approximately 30% to 50% of patients experience a complete response after regional chemotherapy for in-transit melanoma, a subset of patients will develop rapidly progressive disease. In the current era of an expanding armamentarium, including both regional and systemic options for treating advanced melanoma, identifying perioperative factors that predict disease progression may obviate unnecessary morbidity associated with regional therapy and avoid delays in systemic therapy. OBJECTIVE To identify patient-related clinical and pathological variables, as well as procedural factors, that correlate with disease progression. DESIGN Using a prospectively maintained database, we identified patients who either underwent first-time melphalan-based isolated limb infusion (ILI) or first-time hyperthermic isolated limb perfusion (HILP) for in-transit melanoma. Response was defined using modified Response Evaluation Criteria in Solid Tumors for cutaneous disease at 3 months after treatment. Survival analyses were performed using the Kaplan-Meier method, with the differences in survival curves compared using a log-rank test. Potential preoperative and procedural predictors of in-field progressive disease were analyzed using logistic regression. PARTICIPANTS Of the 258 patients included in the database, 215 were identified as having undergone first-time regional therapy. Of these 215 patients, 134 underwent ILI, and 81 underwent HILP. EXPOSURE Regional therapy (ILI or HILP). MAIN OUTCOMES AND MEASURES Complete response or progressive disease. RESULTS Of 134 patients who underwent ILI, 43 (32.1%) experienced in-field progressive disease. Of 81 patients who underwent HILP, 9 (11.1%) experienced in-field progressive disease. The median survival for patients with in-field progressive disease was 20.3 months for the ILI cohort and 15.0 months for the HILP cohort. In general, patients with progressive disease were younger, with advanced-stage melanoma and increased tumor burden. Compared with patients who experienced a complete response, patients with in-field progressive disease after ILI were younger (odds ratio, 1.06 [95% CI, 0.90-0.98]; P = .002). For patients who underwent HILP, no clinically relevant preoperative predictors of in-field progressive disease were identified. Procedural variables, including chemotherapeutic dosing, degree of acidosis or base deficit achieved, and peak temperature attained, were not predictors of in-field progressive disease after ILI or HILP. CONCLUSIONS AND RELEVANCE Patient, clinical, and procedural factors are unreliable predictors of in-field progressive disease after regional therapy in patients with in-transit melanoma. Defining the potential utility of molecular markers in predicting response or failure of regional therapy should be the focus of future research efforts.
    JAMA surgery. 04/2013;
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    ABSTRACT: BACKGROUND: Although the perioperative mortality from hepatic resection has improved considerably, this procedure is still associated with substantial morbidity and resource use. The goal of this investigation was to characterize the incidence, patterns, and risk factors for early reoperation and readmission after hepatectomy. STUDY DESIGN: Perioperative outcomes of 1,281 patients undergoing hepatic resection at an academic center from 1996 to 2009 were analyzed. The indications for early reoperation and readmission (90 days) were reviewed. Multivariate logistic regression analysis was performed to determine variables associated with reoperation and readmission. A scoring system was generated to predict the need for readmission after hepatectomy. RESULTS: Eighty-seven patients (6.8%) required reoperation. The perioperative mortality in patients requiring reoperation was significantly higher than for those not requiring reoperation (23.0% vs 3.4%; p < 0.001). Variables associated with reoperation included male sex, performance of concomitant major nonhepatic procedures, and greater intraoperative blood loss. One hundred and eighty-four patients (14.4%) required readmission. Variables associated with readmission included major hepatectomy, development of major postoperative complications, and index hospitalization >7 days. A Readmission Prediction Score ranging from 0 to 4 was generated and directly correlated with need for readmission. CONCLUSIONS: In the current era of hepatic surgery, early reoperation and readmission remain relatively frequent. As we care for patients who are increasingly receiving regionalized care far from home, we must be mindful of patients at increased risk for readmission. The development of strategies to minimize the complications that necessitate reoperation and readmission is critical to improving patient care.
    Journal of the American College of Surgeons 03/2013; · 4.50 Impact Factor
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    ABSTRACT: INTRODUCTION: Data on recurrence after operation for intrahepatic cholangiocarcinoma (ICC) are limited. We sought to investigate rates and patterns of recurrence in patients after operative intervention for ICC. METHODS: We identified 301 patients who underwent operation for ICC between 1990 and 2011 from an international, multi-institutional database. Clinicopathologic data, recurrence patterns, and recurrence-free survival (RFS) were analyzed. RESULTS: During the median follow up duration of 31 months (range 1-208), 53.5% developed a recurrence. Median RFS was 20.2 months and 5-year actuarial disease-free survival, 32.1%. The most common site for initial recurrence after operation of ICC was intrahepatic (n = 98; 60.9%), followed by simultaneous intra- and extrahepatic disease (n = 30; 18.6%); 33 (21.0%) patients developed extrahepatic recurrence only as the first site of recurrence. Macrovascular invasion (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.34-3.21; P < .001), nodal metastasis (HR, 1.55; 95% CI, 1.01-2.45; P = .04), unknown nodal status (HR, 1.57; 95% CI, 1.10-2.25; P = .04), and tumor size ≥5 cm (HR, 1.84; 95% CI, 1.28-2.65; P < .001) were independently associated with increased risk of recurrence. Patients were assigned a clinical score from 0 to 3 according to the presence of these risk factors. The 5-year RFS for patients with scores of 0, 1, 2, and 3 was 61.8%, 36.2%, 19.5%, and 9.6%, respectively. CONCLUSION: Recurrence after operative intervention for ICC was common. Disease recurred both at intra- and extrahepatic sites with roughly the same frequency. Factors such as lymph node metastasis, tumor size, and vascular invasion predict highest risk of recurrence.
    Surgery 03/2013; · 3.37 Impact Factor
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    ABSTRACT: BACKGROUND: Rapid-response extracorporeal membrane oxygenation (RR-ECMO) has been implemented at select centers to expedite cannulation for patients placed on ECMO during extracorporeal cardiopulmonary resuscitation (ECPR). In 2008, we established such a program and used it for all pediatric venoarterial ECMO initiations. This study was designed to compare outcomes before and after program implementation. METHODS: Between 2003 and 2011, 144 pediatric patients were placed on venoarterial ECMO. Records of patients placed on ECMO before (17 ECPR and 62 non-ECPR) or after (14 ECPR and 51 non-ECPR) RR-ECMO program implementation were retrospectively compared. RESULTS: The peak performance of the ECMO team was assessed by measuring ECMO initiation times for the ECPR patient subgroup (n = 31). There was a shift toward more ECPR initiations achieved in less than 40 minutes (24% pre-RR-ECMO versus 43% RR-ECMO; p = 0.25) and fewer requiring more than 60 minutes (47% pre-RR-ECMO versus 21% RR-ECMO; p = 0.14) after program implementation, although these changes did not reach statistical significance. After multivariable risk adjustment, RR-ECMO was associated with a 52% reduction in neurologic complications for all patients (adjusted odds ratio, 0.48; 95% confidence interval, 0.23 to 0.98; p = 0.04), but the risk of in-hospital death remained unchanged (adjusted odds ratio, 0.99; 95% confidence interval, 0.50 to 1.99; p = 0.99). CONCLUSIONS: Implementation of a pediatric RR-ECMO program for venoarterial ECMO initiation was associated with reduced neurologic complications but not improved survival during the first 3 years of program implementation. These data suggest that development of a coordinated system for rapid ECMO deployment may benefit both ECPR and non-ECPR patients, but further efforts are required to improve survival.
    The Annals of thoracic surgery 03/2013; · 3.74 Impact Factor
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    ABSTRACT: BACKGROUND: This study aims to analyze the midterm outcomes of minimally invasive edge-to-edge mitral valve repair (MVR) with artificial chords (CHORD) or without artificial chords (noCHORD) in patients with mitral regurgitation (MR). METHODS: Records of all patients undergoing edge-to-edge MVR through minithoracotomy at a single institution over a 7-year period were retrospectively reviewed. RESULTS: A total of 186 patients underwent edge-to-edge MVR through minithoracotomy. Disease etiology was posterior prolapse in 73 (39%) and bileaflet prolapse in 77 (41%). Edge-to-edge sutures were used at A1-P1 in 20 patients (11%), A2-P2 in 136 (73%), and A3-P3 in 30 (16%). Annuloplasty rings were placed in 184 patients (99%), with a mean size of 36 ± 5 mm. Mean follow-up was 2 years (range, 0 to 6), with mean mitral gradient 4 ± 2 mm Hg, MR mild or less in 179 of 186 (96%), 4 (2%) late reoperations, and 1 (0.5%) late death. The CHORD patients (n = 71) were more likely than the noCHORD patients (n = 115) to have extensive posterior leaflet pathology (p < 0.01), had longer clamp and pump times (p < 0.01) and were less likely to need leaflet resection (p = 0.002), but had similar postoperative courses. At 3 years, freedom from moderate MR was less in CHORD versus noCHORD patients (88 ± 6 versus 100%, p = 0.001), but freedom from reoperation was similar (96% ± 3% versus 99% ± 1%, p = not significant). CONCLUSIONS: Early results suggest that edge-to-edge MVR can be safe and effective in patients with mitral regurgitation. Edge-to-edge MVR combined with artificial chordae may be useful in selected patients, but with some risk of recurrent moderate MR.
    The Annals of thoracic surgery 02/2013; · 3.74 Impact Factor
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    ABSTRACT: BACKGROUND:: A laparoscopic approach has been proposed to reduce the high morbidity and mortality associated with the Hartmann procedure for the emergency treatment of diverticulitis. OBJECTIVE:: The objective of our study was to determine whether a laparoscopic Hartmann procedure reduces early morbidity or mortality for patients undergoing an emergency operation for diverticulitis. DESIGN:: This is a comparative effectiveness study. A subset of the entire American College of Surgeons National Surgical Quality Improvement Program patient sample matched on propensity for undergoing their procedure with the laparoscopic approach were used to compare postoperative outcomes between laparoscopic and open groups. SETTING:: This study uses data from the American College of Surgeons National Surgical Quality Improvement Program Participant User Files from 2005 through 2009. PATIENTS:: All patients who underwent an emergency laparoscopic or open partial colectomy with end colostomy for colonic diverticulitis were reviewed. MAIN OUTCOME MEASURES:: The main outcome measures were 30-day mortality and morbidity. RESULTS:: Included in the analysis were 1186 patients undergoing emergency partial colectomy with end colostomy for diverticulitis. Among the entire cohort, the laparoscopic group had fewer overall complications (26% vs 41.7%, p = 0.008) and shorter mean length of hospitalization (8.9 vs 11.6 days, p = 0.0008). Operative times were not significantly different between groups. When controlling for potential confounders, a laparoscopic approach was not associated with a decrease in morbidity or mortality. In comparison with a propensity-match cohort, the laparoscopic approach did not reduce postoperative morbidity or mortality. LIMITATIONS:: This study is limited by its retrospective nature and the absence of pertinent variables such as postoperative pain indices, time for return of bowel function, and rates of readmission. CONCLUSIONS:: A laparoscopic approach to the Hartmann procedure for the emergency treatment of complicated diverticulitis does not significantly decrease postoperative morbidity or mortality in comparison with the open technique.
    Diseases of the Colon & Rectum 01/2013; 56(1):72-82. · 3.34 Impact Factor
  • R S Turley, C R Mantyh, J Migaly
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    ABSTRACT: The realm of minimally invasive surgery now encompasses the majority of abdominal operations in the field of colorectal surgery. Diverticulitis, a common pathology seen in most colorectal practices, poses unique challenges to surgeons implementing laparoscopic surgery in their practices due to the presence of an inflammatory phlegmon and distorted anatomical planes, which increase the difficulty of the operation. Although the majority of colon resections for diverticulitis are still performed through a standard laparotomy incision, laparoscopic techniques are becoming increasingly common. A large body of literature now supports laparoscopic surgery to be safe and effective as well as to provide significant advantages over open surgery for diverticular disease. Here, we review the most current literature supporting laparoscopic surgery for elective and emergent treatment of diverticulitis.
    Techniques in Coloproctology 12/2012; · 1.54 Impact Factor
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    ABSTRACT: BACKGROUND: Although a concomitant diaphragm resection might be required at the time of hepatectomy to achieve tumor-free surgical margins, studies addressing its effect on postoperative morbidity and mortality have been inconclusive. The objective of this study was to determine whether the need for diaphragm resection at the time of hepatectomy truly increases 30-day morbidity or mortality using data from the American College of Surgeons National Surgical Quality Improvement Program. STUDY DESIGN: Data were obtained from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program Participant User Files based on CPT coding. All patients undergoing a simultaneous liver and diaphragm resection were propensity-matched to a subset of liver resection patients not undergoing a diaphragm resection. The main outcomes measures were 30-day mortality and morbidity. RESULTS: One hundred and ninety-two patients who underwent combined liver and diaphragm resection were matched to 192 patients treated with liver resection alone. The need for concomitant diaphragm resection was associated with a higher overall complication rate (38.54% vs 28.65%; p = 0.048), major complication rate (33.33% vs 23.44%; p = 0.030), and respiratory complication rate (14.06% vs 7.81%; p = 0.058). Postoperative mortality was similar between groups. Combined diaphragm and liver resection was also associated with longer operative times (median 311 minutes vs 247.5 minutes; p < 0.001), higher rates of intraoperative packed RBC transfusion (33.33% vs 23.44%; p = 0.037), and a longer length of hospitalization (median 7 vs 6 days; p = 0.002). CONCLUSIONS: The results of this study, when taken into account with those reported previously, suggest that the need for diaphragm resection at time of hepatectomy increases postoperative morbidity but not mortality.
    Journal of the American College of Surgeons 12/2012; · 4.50 Impact Factor
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    ABSTRACT: INTRODUCTION: Our objective was to review our 10-year experience of surgical resection for acute ischemic colitis (IC) and to assess the predictive value of previously reported risk-stratification methods. METHODS: We retrospectively reviewed all adult patients at our institution undergoing colectomy for acute IC between 2000 and 2009. Descriptive statistics were calculated. Long-term survival was assessed using Kaplan-Meier methods and in-hospital mortality using multivariate logistic regression. Patients were risk-stratified based on previously reported methods, and discriminatory accuracy of predicting in-hospital mortality was evaluated by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. RESULTS: A total of 115 patients were included for analysis, of which 37 % (n = 43) died in-hospital. The median survival was 4.9 months for all patients and 43.6 months for patients surviving to discharge. Seventeen patients subsequently underwent end-ostomy reversal at our institution, with in-hospital mortality of 18 % (n = 3) and ICU admission for 35 % (n = 6). The discriminatory accuracy of risk stratification in predicting in-hospital mortality based on ROC AUC was 0.75. CONCLUSION: Acute IC continues to remain a very deadly disease. Patients who survive the initial acute IC insult can achieve long-term survival; however, we experienced high rates of death and complications following elective end-ostomy reversal. Risk stratification provides reasonable accuracy in predicting postoperative mortality.
    Journal of Gastrointestinal Surgery 12/2012; · 2.36 Impact Factor

Publication Stats

279 Citations
16 Downloads
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161.14 Total Impact Points

Institutions

  • 2011–2014
    • Duke University
      • Department of Surgery
      Durham, North Carolina, United States
    • University of Pittsburgh
      • Department of Surgery
      Pittsburgh, PA, United States
  • 2007–2014
    • Duke University Medical Center
      • • Department of Surgery
      • • Department of Medicine
      Durham, North Carolina, United States
  • 2011–2013
    • Johns Hopkins University
      • Department of Surgery
      Baltimore, MD, United States