Xiang Fang

University of Wisconsin, Madison, Madison, MS, United States

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Publications (23)81.01 Total impact

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    ABSTRACT: Signet ring cell carcinoma (SRCC) accounts for less than 1% of all colon cancers. We examined the clinicopathological features and prognosis of signet ring cell and mucinous adenocarcinoma (MCC) of colon. A total of 206 patients diagnosed with SRCC from 1995 to 2009 were identified from the VA Central Cancer Registry (VACCR) database. Age, race, histology, grade, lymph node status, stage and type of treatment received data were collected. Out of 206 patients, 173 (84%) were white, 31 (15%) were black, and 2 patients were listed as unknown. Median age of diagnosis was 67 years as compared to 70 years for both mucinous cell (MCC) and non-mucinous adenocarcinoma (NMCC) of colon. Pathological T-stages were as follows: T1 =3%, T2 =5%, T3 =34%, T4 =26%, and unknown 32%. Of the total, 22.3% were located in cecum, 7.7% in appendix, 21.8% in ascending colon, 7.7% in hepatic flexure of colon, 11% in transverse colon, 2.9% in splenic flexure 4.4% in descending colon, and 15.5% in sigmoid colon. 46.5% were lymph node positive, 21% were lymph node negative, and 32.5% were unknown. SRCC were in general poorly differentiated tumors (57%), small proportion of patients included were well-differentiated tumors with focal signet ring cell pathology (10%) and in 33% grade was unknown. Among stage 3 patients, 34% patients received only surgery while 64% received surgery with adjuvant chemotherapy and 2% received chemotherapy alone. The stage specific 5-year survivals for SRCC, MCC and NMCC were--Stage I: 100%, 61%, and 41% respectively (P<0.0001); Stage II: 42%, 58% and 32% respectively (P<0.0001); Stage III: 19%, 41% and 47% respectively (P=0.0002); Stage IV: 1.5%, 7% and 31% respectively (P<0.0001). Median survival of SRCC compared to NMCC was 18.6 vs. 46 months (P<0.0001) and mucinous cell adenocarcinoma versus NMCC was 47.8 and 46 months (P=0.63) respectively. SRCC of colon has poor survival rates compared to other histological subtypes. SRCC presents at an earlier age, has higher tumor grade and advanced stage at diagnosis when compared to mucinous and NMCC of colon. Due to rarity of this disease further prospective multi-institute studies are required for in-depth understanding of this disease.
    Journal of gastrointestinal oncology 02/2014; 5(1):18-24.
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    ABSTRACT: Perioperative outcomes after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) have been rigorously studied; however, inpatient and postdischarge outcomes have not been separately analyzed. The objective of this study was to examine postdischarge 30-day outcomes after elective EVAR. Patients who underwent an elective EVAR for AAA (n = 11,229) were identified from the American College of Surgeons 2005-2010 National Surgical Quality Improvement Project database. Univariable and multivariable logistic regression analyses were performed. The median length of hospital stay was 2 days (interquartile range, 1-3 days). Overall 30-day mortality was 1.0% (n = 117), with 31% (n = 36) of the patients dying after discharge. Overall 30-day morbidity was 10.7% (n = 1204), with 40% (n = 500) of the morbidities being postdischarge. The median time of death and complication was 9 and 3 days, respectively, after surgery. Eighty-eight percent of the wound infections (n = 205 of 234), 33% of pneumonia (n = 44 of 133), and 55% of venous thromboembolism (n = 36 of 65) were postdischarge. Multivariable analyses showed age, congestive heart failure, admission from nursing facility, postoperative pneumonia, myocardial infarction, and renal failure were independently associated with postdischarge mortality, and peripheral arterial disease, female gender, previous cardiac surgery, age, smoking, and diabetes with postdischarge morbidity (P < .05 for all). Patient characteristics associated with a higher risk for postdischarge adverse events after EVAR were identified. Whether improved predischarge surveillance and close postdischarge follow-up of identified high-risk patients will further improve 30-day outcomes after EVAR needs to be prospectively studied.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 12/2013; · 3.52 Impact Factor
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    ABSTRACT: To identify preoperative factors associated with an increased risk of postoperative pneumonia and subsequently develop and validate a risk calculator. The American College of Surgeons' National Surgical Quality Improvement Program, a multicenter, prospective data set (2007-2008) was used. Univariate and multivariate logistic regression analyses were performed. The 2007 data set (N=211,410) served as the training set, and the 2008 data set (N=257,385) served as the validation set. In the training set, 3825 patients (1.8%) experienced postoperative pneumonia. Patients who experienced postoperative pneumonia had a significantly higher 30-day mortality (17.0% vs 1.5%; P<.001). On multivariate logistic regression analysis, 7 preoperative predictors of postoperative pneumonia were identified: age, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, dependent functional status, preoperative sepsis, smoking before operation, and type of operation. The risk model based on the training data set was subsequently validated on the validation data set, with model performance being very similar (C statistic: 0.860 and 0.855, respectively). The high C statistic indicates excellent predictive performance. The risk model was used to develop an interactive risk calculator. Preoperative variables associated with an increased risk of postoperative pneumonia include age, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, dependent functional status, preoperative sepsis, smoking before operation, and type of operation. The validated risk calculator provides a risk estimate for postoperative pneumonia and is anticipated to aid in surgical decision making and informed patient consent.
    Mayo Clinic Proceedings 11/2013; 88(11):1241-9. · 5.79 Impact Factor
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    ABSTRACT: OBJECTIVE:: The objective of this study was to assess the impact of preoperative anemia (hematocrit <39%) on postoperative 30-day mortality and adverse cardiac events in patients 65 years or older undergoing elective vascular procedures. BACKGROUND:: Preoperative anemia is associated with adverse outcomes after cardiac surgery, but its association with postoperative outcomes after open and endovascular procedures is not well established. Elderly patients have a decreased tolerance to anemia and are at high risk for complications after vascular procedures. METHODS:: Patients (N = 31,857) were identified from the American College of Surgeons' 2007-2009 National Surgical Quality Improvement Program-a prospective, multicenter (>250) database maintained across the United States. The primary and secondary outcomes of interest were 30-day mortality and a composite end point of death or cardiac event (cardiac arrest or myocardial infarction), respectively. RESULTS: : Forty-seven percent of the study population was anemic. Anemic patients had a postoperative mortality and cardiac event rate of 2.4% and 2.3% in contrast to the 1.2% and 1.2%, respectively, in patients with hematocrit within the normal range (P < 0.0001). On multivariate analysis, we found a 4.2% (95% confidence interval, 1.9-6.5) increase in the adjusted risk of 30-day postoperative mortality for every percentage point of hematocrit decrease from the normal range. CONCLUSIONS:: The presence and degree of preoperative anemia are independently associated with 30-day death and adverse cardiac events in patients 65 years or older undergoing elective open and endovascular procedures. Identification and treatment of anemia should be important components of preoperative care for patients undergoing vascular operations.
    Annals of surgery 03/2013; · 7.90 Impact Factor
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    ABSTRACT: ABSTRACT BACKGROUND: Although chronic obstructive pulmonary disease (COPD) affects large sections of the population, its effects on postoperative outcomes have not been rigorously studied. Our objectives were to describe the prevalence of COPD in patients undergoing surgery and to analyze the associations between COPD and postoperative morbidity, mortality, and length of stay. METHODS: Patients with COPD who underwent surgery were identified from the NSQIP database (2007 -08). Using this multicenter, prospective dataset (n=468,795), univariate and multivariate analyses were performed. RESULTS: COPD was present in 22,576 (4.82%) patients. These patients were more likely to be older, males, Caucasians, smokers, on corticosteroids, and with lower BMI (p<0.0001 for each). Median length of stay was 4 days for COPD patients vs. 1 day in those without COPD (p<0.0001). Thirty-day morbidity rates were 25.8% and 10.2%, for patients with and without COPD, respectively (p<0.0001). Thirty-day death rate was 6.7% for COPD patients vs. 1.4% in those without COPD (p<0.0001). After controlling for more than 50 comorbidities using logistic regression modeling, COPD was independently associated with higher postoperative morbidity (OR 1.35; 95%CI- 1.30-1.40; p<0.0001) and mortality (OR 1.29; 95%CI- 1.19-1.39; p<0.0001). Multivariate analyses using each individual postoperative complication as the outcome of interest showed that COPD was associated with increased risk for postoperative pneumonia, respiratory failure, myocardial infarction, cardiac arrest, sepsis, return to operating room, and renal insufficiency/failure (p<0.05 for each). CONCLUSION: COPD is common among patients undergoing surgery and is associated with increased morbidity, mortality, and length of stay.
    Chest 01/2013; · 7.13 Impact Factor
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    ABSTRACT: OBJECTIVE: The latest guidelines recommend performance of carotid endarterectomy (CEA) on asymptomatic patients with high-grade carotid stenosis, only if the combined perioperative stroke, myocardial infarction (MI), or death risk is ≤3%. Our objective was to develop and validate a risk index to estimate the combined risk of perioperative stroke, MI, or death in asymptomatic patients undergoing elective CEA. METHODS: Asymptomatic patients who underwent an elective CEA (n = 17,692) were identified from the 2005-2010 National Surgical Quality Improvement Program, a multicenter, prospective database. Multivariable logistic regression analysis was performed with primary outcome of interest being the composite of any stroke, MI, or death during the 30-day periprocedural period. Bootstrapping was used for internal validation. A risk index was created by assigning weighted points to each predictor using the β-coefficients from the regression analysis. RESULTS: Fifty-eight percent of the patients were men with a median age of 72 years. Thirty-day incidences of stroke, MI, and death were 0.9% (n = 167), 0.6% (n = 108), and 0.4% (n = 72), respectively. The combined 30-day stroke, MI, or death incidence was 1.8% (n = 324). On multivariable analysis, six independent predictors were identified and a risk index created by assigning weighted points to each predictor using the β-coefficients from the regression analysis. The predictors included age in years (<60: 0 point; 60-69: -1 point; 70-79: -1 point; ≥80: 2 points), dyspnea (2 points), chronic obstructive pulmonary disease (3 points), previous peripheral revascularization or amputation (3 points), recent angina within 1 month (4 points), and dependent functional status (5 points). Patients were classified as low (<3%), intermediate (3%-6%), or high (>6%) risk for combined 30-day stroke, MI, or death, based on a total point score of <4, 4-7, and >7, respectively. There were 15,249 patients (86.2%) in the low-risk category, 2233 (12.6%) in the intermediate-risk category, and 210 (1.2%) in the high-risk category. CONCLUSIONS: The validated risk index can help identify asymptomatic patients who are at greatest risk for 30-day stroke, MI, and death after CEA, thereby aiding patient selection.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 11/2012; · 3.52 Impact Factor
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    ABSTRACT: For peripheral arterial disease, infrainguinal bypass grafting (BPG) carries a higher perioperative risk compared with peripheral endovascular procedures. The choice between the open and endovascular therapies is to an extent dependent on the expected periprocedural risk associated with each. Tools for estimating the periprocedural risk in patients undergoing BPG have not been reported in the literature. The objective of this study was to develop and validate a calculator to estimate the risk of perioperative mortality ≤30 days of elective BPG. We identified 9556 patients (63.9% men) who underwent elective BPG from the 2007 to 2009 National Surgical Quality Improvement Program data sets. Multivariable logistic regression analysis was performed to identify risk factors associated with 30-day perioperative mortality. Bootstrapping was used for internal validation. The risk factors were subsequently used to develop a risk calculator. Patients had a median age of 68 years. The 30-day mortality rate was 1.8% (n = 170). Multivariable logistic regression analysis identified seven preoperative predictors of 30-day mortality: increasing age, systemic inflammatory response syndrome, chronic corticosteroid use, chronic obstructive pulmonary disease, dependent functional status, dialysis dependence, and lower extremity rest pain. Bootstrapping was used for internal validation. The model demonstrated excellent discrimination (C statistic, 0.81; bias-corrected C statistic, 0.81) and calibration. The validated risk model was used to develop an interactive risk calculator using the logistic regression equation. The validated risk calculator has excellent predictive ability for 30-day mortality in a patient after an elective BPG. It is anticipated to aid in surgical decision making, informed patient consent, preoperative optimization, and consequently, risk reduction.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2012; 56(2):372-9. · 3.52 Impact Factor
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    ABSTRACT: While the epidemic of obesity continues to plague America, bariatric surgery is underused due to concerns for surgical risk among patients and referring physicians. A risk score estimating postoperative mortality (OS-MRS) exists, however, is limited by consideration of only 12 preoperative variables, failure to separate open and laparoscopic cases, a lack of robust statistical analyses, risk factors not being weighted, and being applicable to only gastric bypass surgery. The objective of this study was to develop a validated risk calculator for 30-day postoperative mortality after bariatric surgery. The National Surgical Quality Improvement Program (NSQIP) dataset (2006 to 2008) was used. Patients undergoing bariatric surgery for morbid obesity (n = 32,889) were divided into training (n = 21,891) and validation (n = 10,998) datasets. Multiple logistic regression analysis was performed on the training dataset. The model fit from the training dataset was maintained and was used to estimate mortality probabilities for all patients in the validation dataset. Thirty-day mortality was 0.14%. Seven independent predictors of mortality were identified: peripheral vascular disease, dyspnea, previous percutaneous coronary intervention, age, body mass index, chronic corticosteroid use, and type of bariatric surgery. This risk model was subsequently validated. The model performance was very similar between the training and the validation datasets (c-statistics, 0.80 and 0.82, respectively). The high c-statistics indicate excellent predictive performance. The risk model was used to develop an interactive risk calculator. This risk calculator has excellent predictive ability for mortality after bariatric procedures. It is anticipated that it will aid in surgical decision-making, informed patient consent, and in helping patients and referring physicians to assess the true bariatric surgical risk.
    Journal of the American College of Surgeons 04/2012; 214(6):892-900. · 4.50 Impact Factor
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    ABSTRACT: The use of fenestrated and branched stent graft technology for paravisceral abdominal aortic aneurysms (PAAA) is on the rise; however, its application is limited in the United States to only a few selected centers. Most PAAAs are currently repaired using an open approach. The objective of this study was to determine which patients are at highest risk with open PAAA repair and might benefit most from endovascular repair using fenestrated or branched stent grafts. This was a retrospective cohort study using data from American College of Surgeons National Surgical Quality Improvement Program (NSQIP) hospitals. We identified 598 patients (27.5% women) who underwent elective open PAAA repair from the 2007 to 2009 NSQIP, a prospective database maintained at >250 centers. The main outcome measure was 30-day postoperative mortality. The median patient age was 73 years. The 30-day major morbidity rate was 30.1%, and the mortality rate was 4.5%. Major complications included reintubation (10.0%), sepsis (10.7%), return to operating room (9.2%), new dialysis requirement (5.9%), cardiac arrest or myocardial infarction (4.5%), and stroke (1.2%). Multivariate analyses identified four predictors of postoperative mortality after open PAAA repair: peripheral arterial disease (PAD) requiring revascularization or amputation, chronic obstructive pulmonary disease (COPD), anesthesia time, and female sex. PAD and COPD were present in only 5.2% and 20.4% of patients but were associated with a 16.1% and 9.0% mortality rate, respectively. The mortality rate in women was 7.3% vs 3.5% for men (P = .045). PAD, COPD, and female sex are major risk factors for postoperative mortality after open PAAA repair. Fenestrated or branched stent graft repair may be a more valuable alternative to open repair for patients with one or more of these characteristics who have suitable access vessels.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 12/2011; 55(3):666-73. · 3.52 Impact Factor
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    ABSTRACT: Patients presenting with acute mesenteric ischemia (AMI) sufficiently advanced to require bowel resection have a high morbidity and mortality. The objective of this study was to analyze these patients to determine if certain pre- or intraoperative variables are predictive of death or complications which could then be used to develop a predictive model to aid in surgical decision-making. Patients undergoing bowel resection for AMI were identified from the American College of Surgeons' National Surgical Quality Improvement Program database (2007-2008). Multiple logistic regression analysis was performed. The 861 patients identified had a median age of 69 years. Thirty-day postoperative morbidity and mortality were 56.6% and 27.9%, respectively. Pre- and intraoperative variables significantly associated with postoperative mortality (C statistic, 0.84) included preoperative do not resuscitate order, open wound, low albumin, dirty vs clean-contaminated case, and poor functional status. Pre- and intraoperative variables significantly associated with postoperative morbidity (C statistic, 0.79) included admission from chronic care facility, recent myocardial infarction, chronic obstructive pulmonary disease, requiring ventilator support, preoperative renal failure, previous cardiac surgery, and prolonged operative time. A predictive risk calculator was developed using these variables. Mortality and morbidity rates after bowel resection for AMI are high. A risk calculator for prediction of postoperative mortality and morbidity has been developed and awaits validation in subsequent studies.
    Surgery 10/2011; 150(4):779-87. · 3.37 Impact Factor
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    ABSTRACT: The objective of this study is to explore the prognostic implications of lymphadenectomy in esophageal cancer patients after neo-adjuvant therapy. Retrospective review of a prospectively maintained database identified esophageal cancer patients with locoregional disease who received neo-adjuvant therapy and surgery. Patients were grouped based on the number of nodes resected, pathological lymph node status, and percentage of positive nodes. Kaplan-Meier curves were used to analyze overall survival (OS) and disease-free survival (DFS). Log-rank test was used to compare survival between groups. Eighty-four patients formed the study group. Patients with ≥ 18 nodes resected had a significantly longer median OS than those with <18 nodes resected (68.6 vs. 29.6 months; p = 0.014). Lymph node-negative patients had significantly longer median OS (51.4 vs. 27.4 months; p = 0.025) and DFS (45.3 vs. 12.9 months; p = 0.03) when compared to lymph node-positive patients. Patients with a percentage of positive nodes <0.25 had a significantly longer median OS (31.1 vs. 17.8 months; p = 0.015) and DFS (21.7 vs. 8.9 months; p = 0.021) than patients with ≥ 0.25% positive. Extent of lymphadenectomy, percentage of positive nodes, and pathological lymph node status are significant prognostic markers in patients who undergo esophagectomy after neo-adjuvant therapy.
    Journal of Gastrointestinal Surgery 08/2011; 15(10):1769-76. · 2.36 Impact Factor
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    ABSTRACT: The PROSPECT trial reported no single echocardiographic measurement of dyssynchrony is recommended to improve patient selection for cardiac resynchronization therapy (CRT). In 100 consecutive patients who received CRT, we analyzed 27 ECG and echocardiographic variables to predict a positive response to CRT defined as a left ventricular (LV) end systolic volume decrease of ≥ 15% after CRT. Right ventricular (RV) pacing-induced left bundle branch block (LBBB), time difference between LV ejection measured by tissue Doppler and pulsed wave Doppler (T(TDI-PW)), and wall motion score index (WMSI) were significantly associated with positive CRT response by multivariate regression. We assigned 1 point for RV pacing-induced LBBB, 1 point for WMSI ≤ 1.59, and 2 points for T(TDI-PW) > 50 ms. Overall mean response score was 1.79 ±1.39. Cutoff point for response score to predict positive response to CRT was > 2 by receiver operating characteristic (ROC) analysis. Area under ROC curve was 0.97 (p = 0.0001). Cardiac resynchronization therapy responders in patients with response score > 2 and ≤ 2 were 36/38 (95%) and 7/62 (11%, p < 0.001), respectively. After age and gender adjustment, the response score was related to CRT response (OR = 45.4, p < 0.0001). A response score generated from clinical, ECG and echocardiographic variables may be a useful predictor for CRT response. However, this needs to be validated.
    Archives of medical science : AMS. 08/2011; 7(4):627-33.
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    ABSTRACT: Perioperative myocardial infarction or cardiac arrest is associated with significant morbidity and mortality. The Revised Cardiac Risk Index is currently the most commonly used cardiac risk stratification tool; however, it has several limitations, one of which is its relatively low discriminative ability. The objective of the present study was to develop and validate a predictive cardiac risk calculator. Patients who underwent surgery were identified from the American College of Surgeons' 2007 National Surgical Quality Improvement Program database, a multicenter (>250 hospitals) prospective database. Of the 211 410 patients, 1371 (0.65%) developed perioperative myocardial infarction or cardiac arrest. On multivariate logistic regression analysis, 5 predictors of perioperative myocardial infarction or cardiac arrest were identified: type of surgery, dependent functional status, abnormal creatinine, American Society of Anesthesiologists' class, and increasing age. The risk model based on the 2007 data set was subsequently validated on the 2008 data set (n=257 385). The model performance was very similar between the 2007 and 2008 data sets, with C statistics (also known as area under the receiver operating characteristic curve) of 0.884 and 0.874, respectively. Application of the Revised Cardiac Risk Index to the 2008 National Surgical Quality Improvement Program data set yielded a relatively lower C statistic (0.747). The risk model was used to develop an interactive risk calculator. The cardiac risk calculator provides a risk estimate of perioperative myocardial infarction or cardiac arrest and is anticipated to simplify the informed consent process. Its predictive performance surpasses that of the Revised Cardiac Risk Index.
    Circulation 07/2011; 124(4):381-7. · 15.20 Impact Factor
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    ABSTRACT: Postoperative respiratory failure (PRF) (requiring mechanical ventilation > 48 h after surgery or unplanned intubation within 30 days of surgery) is associated with significant morbidity and mortality. The objective of this study was to identify preoperative factors associated with an increased risk of PRF and subsequently develop and validate a risk calculator. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP), a multicenter, prospective data set (2007-2008), was used. The 2007 data set (n = 211,410) served as the training set and the 2008 data set (n = 257,385) as the validation set. In the training set, 6,531 patients (3.1%) developed PRF. Patients who developed PRF had a significantly higher 30-day mortality (25.62% vs 0.98%, P < .0001). On multivariate logistic regression analysis, five preoperative predictors of PRF were identified: type of surgery, emergency case, dependent functional status, preoperative sepsis, and higher American Society of Anesthesiologists (ASA) class. The risk model based on the training data set was subsequently validated on the validation data set. The model performance was very similar between the training and the validation data sets (c-statistic, 0.894 and 0.897, respectively). The high c-statistics (area under the receiver operating characteristic curve) indicate excellent predictive performance. The risk model was used to develop an interactive risk calculator. Preoperative variables associated with increased risk of PRF include type of surgery, emergency case, dependent functional status, sepsis, and higher ASA class. The validated risk calculator provides a risk estimate of PRF and is anticipated to aid in surgical decision making and informed patient consent.
    Chest 07/2011; 140(5):1207-15. · 7.13 Impact Factor
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    ABSTRACT: Previous reports on postoperative outcomes following thyroid and parathyroid surgery are limited by relatively small sample size. We report 30-day outcomes following thyroid and parathyroid surgery and analyze factors affecting length of stay (LOS) and postoperative adverse events (AEs). The multicenter, prospective, National Surgical Quality Improvement Program (NSQIP) datasets (2007/2008) were used. Multivariable logistic regression and analysis of covariance (ANCOVA) were performed. Patients undergoing thyroidectomy, parathyroidectomy, or both were identified (n = 13,380, 6154, 1535, respectively). Thirty-day mortality was 0.08%, 0.16%, and 0.2%, respectively; 30-day morbidity was 3.50%, 3.02%, and 4.04%, respectively. Mean LOS values were 1.1 ± 1.4, 1.1 ± 2.1, and 1.4 ± 3.1 days, respectively. Congestive heart failure, dependent functional status, dialysis dependence, and chronic corticosteroid use were significantly associated with increased LOS and postoperative AE. Morbidity and mortality rates following thyroid and parathyroid surgery are low. These data could be used by third-party interests, and surgeons should be aware of them to ensure their outcomes are in the national norm.
    Head & Neck 06/2011; 34(4):477-84. · 2.83 Impact Factor
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    ABSTRACT: Postoperative pneumonia (PP) and respiratory failure (PRF) are known to be the most common nonwound complications after bariatric surgery. Our objective was to identify their current prevalence after bariatric surgery and to study the preoperative factors associated with them using data from the American College of Surgeons' National Surgical Quality Improvement Program. Patients undergoing bariatric surgery were identified from the National Surgical Quality Improvement Program (2006-2008), a multicenter, prospective database. Univariate analysis and multivariate logistic regression analysis were performed. Of 32,889 patients, PP was diagnosed in 187 patients (.6%) and PRF in 204 patients (.6%). The overall 30-day morbidity rate was 6.4%, with PP and PRF accounting for 18.7%. The 30-day mortality rate was greater for the patients with PP and PRF than those without (4.3% versus .16% and 13.7% versus .10%, P < .0001). The hospital length of stay was also longer in patients with PP/PRF (P < .0001). On multivariate analysis, congestive heart failure (odds ratio 5.3, 95% confidence interval 1.20-23.26) and stroke (odds ratio 4.1, 95% confidence interval 1.42-11.49) were the greatest preoperative risk factors for PP. Previous percutaneous coronary intervention (odds ratio 2.8, 95% confidence interval 1.64-4.74) and dyspnea at rest (odds ratio 2.64, 95% confidence interval 1.13-6.13) were the factors most strongly associated with PRF. Bleeding disorder, age, chronic obstructive pulmonary disease, and type of surgery were risk factors for both (P < .05). Smoking also predisposed to PP, and diabetes mellitus, anesthesia time, and increasing weight also predisposed to PRF (P < .05 for all). Although PP and PRF are infrequent, they account for one fifth of the postoperative morbidity and are associated with significantly increased 30-day mortality. They can be predicted by various risk factors, emphasizing the importance of patient optimization and careful selection before bariatric surgery.
    Surgery for Obesity and Related Diseases 05/2011; 8(5):574-81. · 4.12 Impact Factor
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    ABSTRACT: The risk-benefit analysis of any operation is influenced by its perioperative complications. Our objective was to examine the relationship between preoperative clinical characteristics and postoperative respiratory failure (PRF: mechanical ventilation for >48 hours after surgery or reintubation) within 30 days of thyroid and parathyroid surgeries. American College of Surgeons' multicenter, prospective, National Surgical Quality Improvement Program (NSQIP) datasets (2007/2008) were used. Multivariable logistic regression was performed. Eighty-three of 20,778 (0.4%) patients developed PRF. Comparing patients who developed PRF to those who did not, 30-day mortality was seen in 13 of 83 versus 11 of 20,695 patients (p < .0001); and mean length of stay (LOS) was 9.1 (±9.5) days versus 1.1 (±1.6) days (p < .0001). Multivariable analysis demonstrated preoperative pneumonia, dependent functional status, dyspnea, dialysis dependence, hypertension, advanced age, and combined thyroid and parathyroid surgery as risk factors for PRF. PRF after thyroid and parathyroid surgeries is uncommon, but associated with significantly increased 30-day morbidity and mortality.
    Head & Neck 03/2011; 34(3):321-7. · 2.83 Impact Factor
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    ABSTRACT: A long-term determinant of survival in resectable colon cancer is the involvement of regional lymph nodes. We evaluated the clinicopathologic factors associated with lymph node retrieval. We conducted a retrospective analysis of patients with resected stage I-III colon cancer in the Veteran's Affairs Central Cancer Registry between 1995 and 2008. One-way ANOVA compared the differences between various groups. Multivariate logistic regression analysis was performed to determine the factors associated with the harvest of 12 or more lymph nodes for pathologic examination. There were 19,240 patients with resectable colon cancer included in our analysis. Mean number of lymph nodes retrieved increased with later year of diagnosis, higher overall stage, higher T descriptor, age <65 years, poorer differentiation and right-sided tumors (P < 0.01 for all covariates). These aforementioned factors are also associated with an increased probability of retrieving 12 or more lymph nodes after surgical resection (P < 0.01 for all covariates). Later year of diagnosis, younger patients, right-sided tumors, poorer differentiation, higher T descriptor and overall stage are associated with increased number of lymph nodes retrieved. These may indicate the presence of an immunological response of tumor versus host affecting lymph node retrieval.
    Journal of Surgical Oncology 02/2011; 104(6):667-71. · 2.64 Impact Factor
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    Journal of Vascular Surgery - J VASC SURG. 01/2011; 53(6).
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    ABSTRACT: Background Metastatic pancreatic cancer is an incurable disease with dismal prognosis, ranging from 2 to 6months. The role of chemotherapy for metastatic pancreatic cancer in very elderly patients (≥80years) has not been well studied.
    Journal of Geriatric Oncology 01/2011; 2(3):209-214. · 1.12 Impact Factor