Person: Sylla, Patricia
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Sylla
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Patricia
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Sylla, Patricia
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Publication Obesity, Outcomes and Quality of Care: BMI Increases the Risk of Wound-Related Complications in Colon Cancer Surgery(Elsevier BV, 2013) Amri, Ramzi; Bordeianou, Liliana; Sylla, Patricia; Berger, DavidBACKGROUND: Obese patients may face higher complication rates during surgical treatment of colon cancer. The aim of this study was to measure this effect at a high-volume tertiary care center. METHODS: All patients with colon cancer treated surgically at a single center from 2004 through 2011 were reviewed. Multivariate regression assessed relationships of complications and stay outcomes with body mass index (BMI) controlling for age, gender, comorbidity score, surgical approach, and history of smoking. RESULTS: In 1,048 included patients, BMI was a predictor of several complications in both laparoscopic and open procedures. For every increase of BMI by one World Health Organization category, the odds ratios were 1.61 (P < .001) for wound infection and 1.54 (P < .001) for slow healing. Additionally, right colectomies had an odds ratio of 3.23 (P = .017) for wound dehiscence. No further associations with BMI were found. CONCLUSIONS: BMI was incrementally associated with wound-related complications, illustrating how the proliferation of obesity relates to a growing risk for surgical complications. As the surgical community strives to improve the quality of care, patient-controllable factors will play an increasingly important role in cost containment and quality improvement.Publication Retrospective Evaluation of Elastic Stain in the Assessment of Serosal Invasion of pT3N0 Colorectal Cancers(Ovid Technologies (Wolters Kluwer Health), 2013) Liang, Wen-Yih; Zhang, Wei-Jun; Hsu, Chih-Yi; Arnason, Thomas; Berger, David; Hawkins, Alexander Tharrington; Sylla, Patricia; Lauwers, Gregory Y.Peritoneal involvement is an important adverse prognostic factor in colorectal cancer (CRC) and determines a shift in the pathologic tumor node metastasis stage. Because peritoneal involvement is difficult to identify, use of special stains highlighting the peritoneal elastic lamina and mesothelial surface has been proposed. This study aims to determine whether use of elastic stain or CK7 immunohistochemistry on a single tissue section can refine the level of tumor invasion and determine whether restaging based on this assessment has prognostic significance in pT3N0 CRCs. Elastic stains were applied to 1 block per case from 244 consecutively resected pT3N0M0 CRCs. CK7 was evaluated in a 169-case subset. The elastic lamina was identified in only 101 cases (41%). Of those, 60 cases (24.6%) displayed elastic lamina invasion (ELI). This finding was associated with significantly worse (P<0.001) disease-free survival (DFS) (5-y DFS=60%) and significantly worse (P=0.01) overall survival (OS) (5-y OS=66.7%) compared with patients with no ELI (5-y DFS=87.8%, OS=92.7%) and those for whom no elastic lamina was identified (5-y DFS=82.5%, OS=86.0%). CK7 staining highlighted mesothelial cells in only 27 of 169 cases tested and helped demonstrate serosal invasion in only 5 cases (3%). In summary, the use of a single elastic stain is a useful and inexpensive method to demonstrate peritoneal involvement by tumor and should be considered for routine use in all pT3N0 CRCs. As tumors with ELI have an adverse prognosis, we propose that they should be upstaged compared with pT3N0 tumors without ELI.Publication En bloc esophageal mucosectomy for concentric circumferential mucosal resection (with video)(Elsevier BV, 2009) Willingham, Field F.; Gee, Denise; Sylla, Patricia; Lauwers, Gregory Y.; Rattner, David; Brugge, WilliamBackground: With conventional EMR, specimens are fragmented, metaplasia may be left behind, and invasive lesions could be missed because of incomplete sampling. Concentric subtotal esophageal mucosectomy would address these limitations. Objective: To examine en bloc esophageal mucosectomy (EEM). Design: A prospective case series. Setting: An academic hospital. Subjects: Nine swine. Interventions: Conventional EMR was performed in the proximal esophagus. The submucosal space was entered, and the distal two thirds of the esophageal mucosa was freed with blunt dissection. A snare was threaded over the column of mucosa to the gastroesophageal junction. The column was resected, and the mucosa was retrieved. Main Outcome and Measurements: Clinical examination, follow-up endoscopy, necropsy, and gross and histopathologic examination. Results: EEM permitted subtotal esophageal mucosectomy in 9 of 9 swine (tissue specimens removed ranged 9-15 cm in length). The mean procedure duration was 110 minutes. In the survival series, 4 of 4 swine thrived after surgery, for 9 to 13 days. At 9 days, there was no evidence of a perforation, stricture, or leak. At 13 days, 2 swine had a mild proximal stricture, which was easily traversed with a 9.8-mm gastroscope. On necropsy, the mediastinal and thoracic cavities were unremarkable in 3 of 4 swine. One swine was found to have a contained abscess containing cellulose, presumably secondary to ingestion of wood-chip bedding material postoperatively. Reepithelialization was present on histologic examination. Limitations: An animal study. Conclusions: EEM is feasible and enabled concentric subtotal esophageal mucosal resection. The technique could completely and circumferentially excise intramucosal lesions. Longer follow-up and larger studies are needed to evaluate infection, stricture, and safety.Publication A pilot study of natural orifice transanal endoscopic total mesorectal excision with laparoscopic assistance for rectal cancer(Springer Nature, 2013) Sylla, Patricia; Bordeianou, Liliana; Berger, David; Han, Kyung S.; Lauwers, Gregory Y.; Sahani, Dushyant; Sbeih, Mohammed A.; Lacy, Antonio M.; Rattner, DavidBackground: The objective of this pilot study was to evaluate the feasibility and safety of natural orifice endoscopic transanal total mesorectal excision (TME) with laparoscopic assistance in a cohort study of five patients with stage I and IIA rectal cancer. Methods: Five eligible patients with node-negative rectal cancer located 4–12 cm from the anal verge were enrolled in an IRB-approved pilot study. All patients underwent transanal endoscopic TME with laparoscopic assistance, hand-sewn coloanal anastomosis, and a diverting loop ileostomy. Primary and secondary end points included adequacy of the mesorectal excision and 30-day postoperative complications, respectively. Results: Between November 2011 and May 2012, three males and two females underwent transanal endoscopic TME with laparoscopic assistance. Patient mean age and BMI were 48.6 ± 9.8 years and 25.7 ± 2.3 kg/m2, respectively. Tumors were located an average of 5.7 ± 2.4 cm from the anal verge and preoperatively staged as T1N0M0 (2), T2N0M0 (1), and T3N0M0 (2). Mean operative time was 274.6 ± 85.4 min with no intraoperative complications. Partial intersphincteric resection was performed in conjunction with transanal endoscopic TME in three patients. Pathologic examination of TME specimens demonstrated complete mesorectal excision in all cases with negative proximal, distal, and radial margins. Mean length of hospital stay was 5.2 ± 2.6 days and three minor complications occurred, including one ileus and two cases of transient urinary dysfunction. At a mean early follow-up of 5.4 ± 2.3 months, all patients remain disease-free. Conclusions: In this pilot study of five patients with rectal cancer, transanal endoscopic TME with laparoscopic assistance is feasible and safe, and is a promising alternative to open and laparoscopic TME. Evaluation of long-term functional and oncologic outcomes of this approach is needed before widespread adoption can be recommended.Publication The effect of neoadjuvant chemoradiation therapy on the prognostic value of lymph nodes after rectal cancer surgery(Elsevier BV, 2010) Klos, Coen L.; Shellito, Paul; Rattner, David; Hodin, Richard; Cusack, James; Bordeianou, Liliana; Sylla, Patricia; Hong, Theodore; Blaszkowsky, Lawrence; Ryan, Davis P.; Lauwers, Gregory Y.; Chang, Yuchiao; Berger, DavidBackground: Neoadjuvant therapy may affect the prognostic impact of total lymph node harvests and lymph node positivity after surgery for rectal cancer. Methods: We performed a retrospective review of 390 consecutive patients with histologically confirmed rectal cancer. Postoperative follow-up evaluation and survival were confirmed via medical record review. The impacts of lymph node positivity and total lymph node harvest on survival and recurrence are reflected as proportional hazard ratios (HRs). Results: A total of 221 patients underwent neoadjuvant therapy, of whom 75 had positive nodes. Node-positive patients showed a significantly shorter survival time (HR, 2.89; P = .002) and time to local recurrence (HR, 6.36; P = .031) compared with patients without positive nodes. Survival and recurrence were not significantly different between patients with a total harvest of fewer than 12 nodes and patients with a higher lymph node harvest. Conclusions: After neoadjuvant treatment and total mesorectal excision, lymph node positivity is associated with significantly shorter survival and time to local recurrence in rectal cancer patients, whereas absolute total lymph node harvests likely have little impact on prognosis.Publication Impact of Screening Colonoscopy on Outcomes in Colon Cancer Surgery(American Medical Association (AMA), 2013) Amri, Ramzi; Bordeianou, Liliana; Sylla, Patricia; Berger, DavidImportance: Screening colonoscopy seemingly decreases colorectal cancer rates in the United States. In addition to removing benign lesions and preventing progression to malignancy, screening colonoscopy theoretically identifies asymptomatic patients with early-stage disease, potentially leading to higher survival rates. Objectives: To assess the effect of screening colonoscopy on outcomes of colon cancer surgery by reviewing differences in staging, disease-free interval, risk of recurrence, and survival and to identify whether diagnosis through screening improves long-term outcomes in- dependent of staging. Design: Retrospective review of prospectively maintained, institutional review board-approved database. Setting: Tertiary care center with high patient volume. Patients: All patients who underwent colon cancer surgery at Massachusetts General Hospital from January 1, 2004, through December 31, 2011. Intervention: Colon cancer surgery. Main Outcomes and Measures: Postoperative staging, death, and recurrence, measured as incidence and time to event. Results: A total of 1071 patients were included, with 217 diagnosed through screening. Patients not diagnosed through screening were at risk for a more invasive tumor (≥T3: relative risk [RR]=1.96; P<0.001), nodal disease (RR=1.92; P<0.001), and metastatic disease on presentation (RR=3.37; P<0.001). In follow-up, these patients had higher death rates (RR=3.02; P<0.001) and recurrence rates (RR=2.19; P=0.004) as well as shorter survival (P<0.001) and disease-free intervals (P<0.001). Cox and logistic regression controlling for staging and base- line characteristics revealed that death rate (P=0.02) and survival duration (P=0.01) were better stage for stage with diagnosis through screening. Death and metastasis rates also remained significantly lower in tumors without nodal or metastatic spread (all P<0.001). Conclusions and Relevance: Patients with colon cancer identified on screening colonoscopy not only have lower-stage disease on presentation but also have better outcomes independent of their staging. Compliance to screening colonoscopy guidelines can play an important role in prolonging longevity, improving quality of life, and reducing health care costs through early detection of colon cancer.Publication Colon cancer surgery following emergency presentation: effects on admission and stage-adjusted outcomes.(Elsevier, 2015) Amri, Ramzi; Bordeianou, Liliana; Sylla, Patricia; Berger, DavidBackground: Emergency presentation with colon cancer is intuitively related to advanced disease. We measured its effect on outcomes of surgically treated colon cancer. Methods: A retrospective cohort of 1,071 surgical colon cancer patients (2004 to 2011), with 102 emergency cases requiring surgery within the index admission, was analyzed. Results: Emergency patients required longer surgeries (median 141 vs 124 minutes; P = .04), longer median admissions (8% vs 5%; P < .001), more readmissions (12.7% vs 7.1%; P = .040), and perioperative mortality (7.8% vs .8%; P < .001). Surgical pathology displayed higher rates of node-positive disease (56.6% vs 38.6%; P < .001), extramural vascular invasion (39.6% vs 29.1%; P = .021), and metastatic disease (19.6% vs 8%; P < .001). Consequently, adjusting for staging, emergency presentations had considerably higher mortality (odds ratio = 2.07; P = .003) and shorter disease-free survival (hazard ratio = 1.39; P = .042). Conclusions: Emergency presentation is a stage-independent poor prognostic factor associated with aggressive tumor biology, resulting in longer surgeries and admissions, frequent readmissions, worsening outcomes, and increasing healthcare costs.Publication Variations in Metastasis Site by Primary Location in Colon Cancer(Springer Science + Business Media, 2015) Amri, Ramzi; Bordeianou, Liliana; Sylla, Patricia; Berger, DavidObjective: The purpose of this paper is to determine whether sites of distant recurrence are associated with specific locations of primary disease in colon cancer. Methods: A cohort including all patients (n = 947) undergoing a segmental colonic resection for colon cancer at our center (2004–2011) comparing site-specific metastatic presentation and recurrence rates, as well as their respective multivariable American Joint Committee on Cancer (AJCC) stage-adjusted hazard ratios (mHR). Results: Right-sided colectomies (n = 557) had a lower overall metastasis rate (24.8 % vs. 31.8 %; P = 0.017; mHR = 1.24 [95% CI: 0.96–1.60]; P = 0.011) due to significantly lower pulmonary metastasis in follow-up (2.7 % vs. 9 %; P < 0.001; mHR = 0.32 [95% CI: 0.17–0.58]; P = 0.001) and lower overall liver metastasis rate (15.6 vs. 22.1 %; P = 0.012; mHR = 0.74 [95% CI: 0.55–0.99];P = 0.050). Left colectomies (n = 127) had higher rates of liver metastasis during follow-up (9.4 % vs. 4.8 %; P = 0.029; mHR = 1.64 [95% CI: 0.86–3.15]; P = 0.134). Sigmoid resections (n = 238) had higher baseline rates of liver metastasis (17.1 % vs. 11.3 %; P = 0.015) and higher cumulative rates of lung (12.2 % vs. 5.4 %; P < 0.001; mHR = 2.26 [95 % CI: 1.41–3.63]; P = 0.001) and brain metastases (2.3 % vs. 0.6 %; P = 0.033; mHR = 4.03 [95% CI: 1.14–14.3]; P = 0.031). Other sites of metastasis, including the (retro) peritoneum, omentum, ovary, and bone, did not yield significant differences. Conclusions: Important variations in site-specific rates of metastatic disease exist within major resection regions of colon cancer. These variations may be important to consider when evaluating options for adjuvant treatment and surveillance after resection of the primary disease.