Neil Hyman

The University of Chicago Medical Center, Chicago, Illinois, United States

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Publications (163)902.79 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: The incidence of rectal cancer in younger patients continues to increase. Because most of these patients do not meet criteria for routine colorectal cancer screening, diagnosis may be delayed, potentially resulting in adverse outcomes. The aim of this study was to determine whether patients under the age of 50 years with rectal cancer have a delay in diagnosis and treatment leading to a worse overall prognosis. Methods: A case control study of patients diagnosed with rectal adenocarcinoma in an academic medical center from 1997 to 2007 under 50 years of age were matched 1:1 to randomly selected patients over the age of 50 years by sex and date of diagnosis. Time to diagnosis, time to treatment, staging of the American Joint Committee on Cancer, and 5-year overall survival were compared. Results: The overall time to treatment from symptom onset was 217 days for patients under the age of 50 years versus 29.5 days if over 50 years of age (P < .0001). The primary delay occurred between the onset of symptoms and presentation to the initial physician. There was no difference in stage at the time of diagnosis or 5-year survival (64% vs 71%, P = .39 and P = .54, respectively). Conclusions: Patients with rectal cancer under the age of 50 years have symptoms for a considerable period of time before seeking medical care and are referred in less timely manner to specialists. However, the delay in diagnosis did not adversely impact stage on presentation or 5-year survival.
    No preview · Article · Nov 2015 · American journal of surgery
  • Jesse Moore · Andrew Pellet · Neil Hyman
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    ABSTRACT: Background: Laparoscopic colectomy has a shorter length of stay and less analgesic requirements than its open counterpart. Studies have suggested a learning curve of 30 cases. It is uncertain whether surgeons in rural settings have the case volume to acquire and maintain the necessary skill set. The aim of this study was to analyze the volume of colon resections performed by surgeons in rural practice. Methods: We performed a retrospective cohort study of the laparoscopic and open partial colectomy case volumes of rural general surgeons seeking American Board of Surgery recertification in 2012. Results were stratified by large and small rural area. Results: One hundred ninety-seven surgeons were classified as practicing in a rural setting (large rural-150, small rural-47). The median open partial colectomy frequency for large rural surgeons was 7 cases and 4 for small rural surgeons. Median annual partial laparoscopic colectomy volume was 1.0 for large rural surgeons and 0.0 for small rural surgeons. Approximately half of surgeons in both groups did not perform a laparoscopic partial colectomy. Conclusions: Industry and financial pressures to promote laparoscopic colectomy may not promote optimal patient outcomes in rural settings, as safety concerns may outweigh the modest benefits of the procedure. Although referral to remote high-volume centers could be advocated, the need for rural general surgeons to perform urgent colectomy for acute indications and the desire of many patients to have care close to home must also be considered.
    No preview · Article · Sep 2015 · Journal of Gastrointestinal Surgery
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    ABSTRACT: Intestinal anastomotic leak (AL) is one of the most dreaded and challenging complications encountered after bowel surgery. Despite advances in surgical technique and innovation, anastomotic leak rates remain relatively unchanged over the past several decades. Management of an anastomotic leak typically necessitates a lengthy hospitalization often associated with considerable morbidity, suffering as well as overwhelming cost and resource utilization. The aim of this article is to provide evidence-based and experience-driven advice to a practicing surgeon on the management and reoperative strategies following an anastomotic leak.
    No preview · Article · Sep 2015 · Seminars in Colon [amp ] Rectal Surgery
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    ABSTRACT: For medically refractory or obstructive Crohn's disease (CD), ostomy surgery remains an important therapeutic option. Outcomes and complications of this approach have not been well described in the era of biological therapies. Our study aims to characterize CD patients undergoing ostomy creation and assess outcome predictors. We performed a retrospective chart review of CD patients who underwent ostomy creation in our center from 2011 to 2014. Data collected include patient demographics, detailed disease- and surgery-related variables, and clinical outcomes after 26 weeks of follow-up. Of the 112 patients, 54 % were female, the median age was 39 years (range 19-78), the median disease duration was 13 years (range 0-50), 54 % had ileo-colonic disease, 55 % had stricturing phenotype, and 59 % had perianal disease. Sixty-two percent received end ostomies, and 38 % received loop ostomies. The leading indications for surgery were stricturing, fistulizing, and perianal disease (35 %). Forty-three (38 %) patients had 76 major complications, including dehydration (22 cases), intra-abdominal infection (16), and obstruction (14). Increased major postoperative complications correlated with penetrating disease (p = 0.02, odds ratio [OR] = 5.52, 95 % confidence interval [CI] = 1.25-24.42), the use of narcotics before surgery (p = 0.04, OR = 2.54, 95 % CI = 1.02-6.34), and loop ostomies (p = 0.004, OR = 4.2, 95 % CI = 1.57-11.23). Penetrating phenotype, the use of narcotics before surgery, and loop ostomies are associated with major complications in CD patients undergoing ostomy creation. These findings may influence risk management of CD patients needing ostomies.
    No preview · Article · Aug 2015 · Journal of Gastrointestinal Surgery
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    ABSTRACT: Care protocols can facilitate effective management of injured patients across a spectrum of providers. It is uncertain whether patient care is compromised when a full time trauma surgeon is not on call in the rural setting, where manpower may be a challenge. A retrospective cohort study was performed at an academic medical center with a level I trauma center. Patients admitted to the trauma service from 2007 to 2012 were compared with respect to mortality, missed injuries, delay in diagnosis, and length of stay based on whether they were admitted to the trauma service when a full-time trauma surgeon was on call. A total of 2,571 injured patients were admitted during the study period; 1,621 directly to the trauma service. Of those, 1,415 patients were initially seen by a trauma surgeon (group A) and 206 by a nontrauma surgeon (group B). Demographics were similar except that the trauma attending patients were somewhat older (44.7 vs 39.4 years, P = .002). There was no difference in the mean injury severity score (17.0 vs 16.0, P = .13) or Glasgow Coma Scale (12.7 vs 12.3, P = .7) between the 2 groups. There were 128 deaths; mortality rate in group A was 7.9% versus 7.7% for group B (P = .54). There was no difference in the incidence of delayed diagnosis or missed injuries (3.0 vs 3.4%, P = .8; .4 vs .9%, P = .27, respectively). The mean length of stay was shorter (7.9 vs 6.3, P = .016) in group B. There was no increase in mortality, delayed diagnosis, or missed injuries when nontrauma surgeons took call. Systems of care and algorithms can be developed that provide staffing flexibility yet maintain safe and effective care to trauma patients in the rural setting. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Aug 2015 · American journal of surgery

  • No preview · Article · Apr 2015 · Gastroenterology

  • No preview · Article · Apr 2015 · Gastroenterology
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    ABSTRACT: Parastomal herniation is a common clinical occurrence. Historically, there has been a high recurrence rate after repair, and conservative management is usually recommended for patients with mild symptoms. When operative intervention is warranted, we opt for a laparoscopic mesh sublay over the fascial defect and lateralization of the stoma limb, or the Sugarbaker technique. In patients who are considered poor risk for laparoscopy/laparotomy requiring repair, we perform a fascial onlay with mesh utilizing an anterior circumstomal approach.
    No preview · Article · Dec 2014 · Journal of Gastrointestinal Surgery
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    ABSTRACT: There are various surgical techniques used treat anal fistulas. The adoption and success rates of newer techniques have not been clearly established.
    No preview · Article · Nov 2014 · Diseases of the Colon & Rectum
  • Source
    Mohammad S. Jafferji · Neil Hyman
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    ABSTRACT: Background The “best’ operation in the setting of acute complicated diverticulitis has been debated for decades. Multiple studies, including a recent prospective randomized trial, have reported improved outcomes with primary anastomosis. The aim of this study was to determine whether surgeon or patient specific factors drive the choice of operative procedure. Study Design Consecutive adult patients with sigmoid diverticulitis requiring emergent operative treatment for acute complicated diverticulitis from 1997-2012 at an academic medical center were identified from a prospectively maintained complications database. Patient characteristics, surgeon, choice of operation and outcomes including postoperative complications and stoma reversal were noted. The use of primary anastomosis and associated outcomes between colorectal and noncolorectal surgeons were compared. Results 151 patients underwent urgent resection during the study period and 136 met inclusion criteria. 82 resections (65.1%) were performed by noncolorectal surgeons and 44 by colorectal surgeons (34.9%). Noncolorectal surgeons performed more HP (68.3% vs 40.9%, p=0.01) despite similar demographics, ASA classification and Hinchey stage. Length of stay, time to stoma reversal, ICU days and postop complications were lower in the colorectal group (43.2% vs 16.7, p=0.02). Conclusions Although patient specific factors are important, surgeon is a potent predictor of operation performed in the setting of severe acute diverticulitis. A more aggressive approach to primary anastomosis may lower the complication rate after surgical treatment for severe acute diverticulitis.
    Preview · Article · Jun 2014 · Journal of the American College of Surgeons
  • Larson Erb · Neil H. Hyman · Turner Osler
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    ABSTRACT: Background Anastomotic leak is a serious complication of gastrointestinal surgery. Abnormal vital signs are often cited in retrospective peer review and medicolegal settings as evidence of negligence in the failure to make an early diagnosis. We aimed to profile the postoperative course of patients who undergo intestinal anastomosis and determine how reliably abnormal vital signs predict anastomotic leaks. Study Design Consecutive patients undergoing bowel resection with anastomosis at an academic medical center between July 2009 through July 2011 were identified from a prospective complication database. The electronic medical record was queried for postoperative vital signs and laboratory studies which were digitally abstracted. Abnormal values were defined as temperature >38°C, white blood cell count ≤4000 or ≥12,000 cells/uL, systolic blood pressure ≤80 mmHg or diastolic blood pressure ≤50 mmHg, pulse ≥100 beats per minute and respiratory rate ≥20 breaths per minute. Patients who developed an anastomotic leak were compared to those with an uncomplicated postoperative course. Results Of the 452 patients, 141 (31.2%) suffered a total of 271 complications, including 19 anastomotic leaks. Even in “uncomplicated” recoveries, tachycardia and tachypnea were almost routine, occurring in more than half of the patients frequently throughout the postoperative period. Hypotension, fever and leukocytosis were also remarkably common. The positive predictive value of any aberrant vital sign or white blood cell count ranged between 4-11%. Conclusions Abnormal vital signs are extremely common after bowel resection with anastomosis. Even sustained aberrant vital signs and/or leukocytosis is not necessarily suggestive of a leak or other postoperative complication.
    No preview · Article · Jun 2014 · Journal of the American College of Surgeons
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    ABSTRACT: A large proportion of patients with a colostomy or an ileostomy develop parastomal hernias. The placement of a reinforcing material at the stoma site may reduce parastomal hernia incidence. We aimed to assess the safety and efficacy of stoma reinforcement with sublay placement of non-cross-linked porcine-derived acellular dermal matrix at the time of stoma construction. This is a randomized, patient- and third-party assessor-blind, controlled trial. This study took place in colorectal/general surgery institutions. Patients were prospectively randomly assigned to undergo standard end-stoma construction with or without porcine-derived acellular dermal matrix reinforcement. Patients undergoing construction of a permanent stoma were eligible. A total of 113 patients (59 men, 54 women; mean age, 60 years; mean BMI, 25.4 kg/m) participated: 58 controls and 55 with reinforcement. The incidence of parastomal hernia, safety, and stoma-related quality of life were assessed. Intraoperative complications and blood loss were similar between groups. Quality-of-life scores were similar through 24 months of follow-up. At 24 months of follow-up, the incidence of parastomal hernias was similar for both groups (12.2% of the porcine-derived acellular dermal matrix group and 13.2% of controls). Study limitations include the inclusion of ileostomy and colostomy patients, open and laparoscopic techniques, and small numbers of patients at follow-up. Safety and quality-of-life data from this randomized control trial show similar outcomes in both groups. Prosthetic reinforcement of stomas was safe, but it did not significantly reduce the incidence of parastomal hernia formation. Identification no. NCT00771407.
    No preview · Article · May 2014 · Diseases of the Colon & Rectum

  • No preview · Article · May 2014 · Gastroenterology
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    ABSTRACT: Despite increasing interest in local microvascular alterations associated with inflammatory bowel disease (IBD), the potential contribution of a primary systemic vascular defect in the etiology of IBD is unknown. We compared reactivity of large diameter mesenteric arteries from segments affected by Crohn disease (CD) or ulcerative colitis (UC) to an uninvolved vascular bed in both IBD and control patients. Mesenteric and omental arteries were obtained from UC, CD, and non-IBD patients. Isometric arterial contractions were recorded in response to extracellular potassium (K(+)) and cumulative additions of norepinephrine (NE). In addition, relaxation in response to pinacidil, an activator of adenosine triphosphate-sensitive K(+) channels was examined. Contraction to K(+) and sensitivity to NE were not significantly different in arteries from CD, UC, and controls. Relaxation to pinacidil was also similar between groups. Potassium-induced contractions and sensitivity to NE and pinacidil were not significantly different in large diameter mesenteric and omental arteries obtained from IBD patients. Furthermore, there was no significant difference in the sensitivity to K(+), NE, and pinacidil between mesenteric and omental arteries of CD and UC patients and those from non-IBD patients. Our results suggest an underlying vascular defect systemic to CD or UC patients is unlikely to contribute to the etiology of IBD.
    No preview · Article · Apr 2014 · Journal of Surgical Research
  • Article: Mentorship
    Joseph Platz · Neil Hyman
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    ABSTRACT: The world of medicine is in a state of flux with major and substantive changes in its educational model. Students, residents, and junior attendings can no longer rely entirely on experiential development through clinical immersion. Instead, to attain similar levels of knowledge, technique, and situational comfort, there must be innovations in medical education that take advantage of the experience of mentors. Mentoring has been a part of medicine and surgery since the days of apprenticeship. Mentors must now teach more basic medicine than ever before and adapt to changes in the structure of medical education such as the use of simulation, yet still continue to foster career development among trainees and junior colleagues. For mentoring to succeed and benefit mentees, it must be supported. This patronage starts with each local university or hospital system but eventually must permeate the greater medical culture.
    No preview · Article · Dec 2013 · Clinics in Colon and Rectal Surgery
  • Whitney Young · Neil Hyman · Turner Osler
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    ABSTRACT: Background: Patients with Crohn's disease typically undergo computed tomography (CT) scans periodically over the course of their chronic disorder, requiring only modest doses of ionizing radiation. However, previous studies have suggested there is a subgroup of patients with Crohn's disease who undergo frequent CT scans with an associated increase in health care expenditures and possible overexposure to radiation, potentially placing such patients at increased risk for cancer. The aim of our study was to characterize and define this potentially vulnerable cohort using a relatively homogeneous surgical population. Methods: Consecutive patients who underwent ileocolic resection for Crohn's disease from January 2000 to September 2010 at an academic medical center were identified from a prospectively maintained database. Only patient CT scans remote from surgery or hospitalization were considered in the analysis. The number of outpatient CT scans, physician visits, and coexisting psychiatric and functional diagnoses were recorded from retrospective chart review. Patients who were considered high CT scan utilizers were compared with patients who were low utilizers. Results: Sixty-three patients underwent 126 CT scans during the study period, however, 4 of the patients accounted for 52 (41%) of the studies. Compared with the overall study population, the subset of 4 patients (high utilizers) had a median of 66 clinic visits (P < 0.001) and 40 emergency department visits (P < 0.001). All 4 patients were on chronic narcotic medication, and only 1 did not have a concomitant functional disorder. Missed appointments and the absence of prescribed antidepressants were common among patients with high CT use. Conclusions: Although use of CT appears moderate in surgical patients with Crohn's disease overall, there is a subset of patients with chronic pain and psychiatric diagnoses, who frequently miss appointments, and account for a markedly disproportionate number of scans performed. Interestingly, use of antidepressants in patients with Crohn's disease was strongly associated with fewer scans, suggesting an opportunity for therapeutic intervention.
    No preview · Article · Nov 2013 · Postgraduate Medicine
  • Ari Garber · Neil Hyman · Turner Osler
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    ABSTRACT: Primary anastomosis with or without proximal diversion is increasingly applied to patients requiring urgent colectomy for complicated disease of the left colon. As such, the Hartmann procedure is now often restricted to patients who are unstable or otherwise poor candidates for primary anastomosis. We sought to define the complication rate of Hartmann takedown in a contemporary setting. Consecutive adult patients undergoing colostomy takedown with colorectal anastomosis at an academic teaching hospital from January 1, 2001, to December 31, 2010, were included in the study. Complications were captured prospectively by a single trained nurse practitioner. Demographics, body mass index, American Society of Anesthesiologists (ASA) classification, interval between Hartmann procedure and subsequent takedown, surgical indication, duration of surgery, surgeon volume and specialty, length of stay, and complications were recorded. One hundred three patients underwent Hartmann reversal by 16 different surgeons; 7 of these surgeons performed 4 or fewer procedures during the study period. During the same time period, 334 patients underwent a Hartmann procedure at our institution. Seventy-seven of 104 patients (74%) had their index resection for complicated diverticulitis; an anastomotic leak was the second most common indication. The median age was 61 years (range 31 to 84 years), and the interval from Hartmann procedure to reversal ranged from 87 to 1,489 days. Only 8 patients (7.7%) had an ASA of 1. Thirty patients (29.1%) had postoperative complications, and 12 (11%) had 2 or more complications. There were 2 deaths and 4 anastomotic leaks, and 7 patients had inadvertent enterotomies. Only ASA status predicted postoperative complications (P = .01). Hartmann takedown is a morbid operation with a substantial risk of inadvertent enterotomy and serious complications. Excluding cases referred from elsewhere, there were more than 5-fold the number of Hartmann procedures than takedowns performed during the study period. This suggests that Hartmann procedures are typically restricted to patients who are also poor candidates for takedown and that their colostomy is likely to be permanent.
    No preview · Article · Sep 2013 · American journal of surgery
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    ABSTRACT: Stage-specific survival for colon cancer improves when more lymph nodes are reported in the surgical specimen. This has led to a minimum standard of identifying 12 lymph nodes as a quality indicator. The aim of this study was to determine whether the addition of Schwartz solution increases node yield and impacts pathologic staging. This is a prospective cohort study. The study was conducted in an academic medical center. Included were 104 consecutive patients with colorectal cancer. Lymph node counts before and after specimen treatment with Schwartz solution and incidence of upstaging were measured. An additional 20 minutes (interquartile range, 15-40 minutes) was spent searching for lymph nodes, increasing the median number of nodes from 22.5 to 29.0 nodes. However, only 1 patient was upstaged. Schwartz solution decreased the number of specimens with less than 12 lymph nodes from 15 to 6. The following factors were associated with Schwartz solution leading to the detection of additional nodes: number of nodes detected initially with formalin only (p < 0.000), mesenteric fat volume (p < 0.000), mesenteric fat weight (p < 0.000), length of specimen (p < 0.016), tumor greatest dimension (p < 0.016), patient body surface area (p < 0.034), and patient age (p < 0.003). Clinical data for this study were obtained retrospectively and were not available for all of the patients. Although Schwartz solution increased the number of nodes detected in 95% of patients and improved compliance with the 12-node standard for colon resection, there was minimal impact on cancer staging. Upstaging is unlikely to explain the increase in overall survival in patients with higher lymph node counts, casting doubt on the validity of this process measure as a meaningful quality indicator. Rather, the lymph node count may be a reflection of inherent tumor biology or host-related factors.
    No preview · Article · Sep 2013 · Diseases of the Colon & Rectum
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    ABSTRACT: Aim: Reservoir ileitis (pouchitis) is the most common complication after pelvic pouch surgery for ulcerative colitis and the aetiology remains largely unknown. The anal transition zone (ATZ) contains the only remaining colonic epithelium after ileal pouch anal anastomosis (IPAA) and may provide important clues as to whether ulcerative colitis and pouchitis share a common pathogenesis. The aim of this study was to evaluate longitudinally the long-term histological changes in the ATZ and their relationship to the incidence of pouchitis. Method: Patients with a double-stapled IPAA for ulcerative colitis at an academic medical centre with at least 10 years of clinical and histological follow-up were identified from a prospective database. Annual ATZ and pouch biopsies were taken and interpreted by two expert gastrointestinal pathologists. ATZ histological variability score, the incidence of pouchitis, and function were correlated over time. ATZ biopsies were scored from one to three based on the extent of inflammation. Results: Sixteen of the 114 patients having IPAA fulfilled the criteria for admission to the study. There were 179 biopsies of the ATZ. All exhibited variability in ATZ histology over time and 81% had a 2-unit change in their inflammatory score. There was no correlation between pouchitis and histological severity score of the ATZ. Similarly, function over time did not vary with the intensity of ATZ inflammation. Conclusion: ATZ inflammation varies substantially over time in most patients. But these changes from year to year did not correlate with function or the occurrence of pouchitis.
    No preview · Article · Jun 2013 · Colorectal Disease
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    ABSTRACT: Background: Multimodality fast-track protocols have been shown to enhance recovery after bowel resection. However, it remains unclear which of the components impact outcomes and whether processes actually occur as intended. Methods: Consecutive patients who underwent elective bowel resection at a university teaching hospital under a standardized fast-track recovery protocol were compared with patients who underwent similar procedures before protocol initiation. Compliance was measured with the 7 major elements of the protocol: administration of nonopioid analgesia, perioperative lidocaine, nasogastric tube removal, early feeding, early ambulation, and fluid restriction. Results: Eighty pathway patients were compared with 87 conventional patients. Only 3 of the 7 major components were successfully implemented. Fluid restriction was achieved in only 2 patients. Pain scores and ileus-related morbidities were comparable with the exception of nasogastric tube reinsertion, which was required twice as often in pathway patients (17 vs 8, P = .02). Thirteen pathway patients were readmitted compared with 7 control patients (P = .11). Conclusions: The delivery of expected care cannot be assumed. There was no discernible benefit in patient outcomes.
    No preview · Article · Jun 2013 · American journal of surgery

Publication Stats

5k Citations
902.79 Total Impact Points

Institutions

  • 2015
    • The University of Chicago Medical Center
      • Department of Surgery
      Chicago, Illinois, United States
  • 2014
    • University of Chicago
      Chicago, Illinois, United States
  • 2002-2014
    • University of Vermont Medical Center
      Burlington, Vermont, United States
  • 1993-2014
    • University of Vermont
      • • Department of Surgery
      • • Division of General Surgery
      Burlington, Vermont, United States
  • 2008
    • Massachusetts General Hospital
      • Department of Surgery
      Boston, Massachusetts, United States
  • 2005-2008
    • Fletcher Allen Health Care
      Burlington, Vermont, United States
  • 2006
    • Central Vermont Medical Center
      Barre, Vermont, United States
  • 2004
    • Universität Regensburg
      Ratisbon, Bavaria, Germany