9th September 2018

Visceral obesity is associated with outcomes…

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Ballian N, Lubner MG, Munoz A, Harms BA, Heise CP, Foley EF, Kennedy GD.

J Surg Oncol. 2012 Mar 15;105(4):365-70. doi: 10.1002/jso.22031. Epub 2011 Jul 12.

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

Abstract

BACKGROUND AND OBJECTIVES:

General obesity, measured by the body mass index (BMI), increases the technical difficulty of total mesorectal excision (TME) but does not affect oncologic outcomes. The purpose of this study is to compare visceral and general obesity as predictors of outcomes of TME for rectal adenocarcinoma.

METHODS:

Adult patients undergoing TME for rectal adenocarcinoma were retrospectively identified. Preoperative computed tomography scans were used to measure abdominal circumference (AC), visceral (VFA), and subcutaneous fat area (SFA). BMI, AC, VFA, SFA, total fat area (TFA, sum of VFA and SFA), and VFA/SFA ratio were examined for association with operative, postoperative, oncologic, and survival outcomes in a univariate analysis model.

RESULTS:

Between 1999 and 2009, 113 patients met inclusion criteria. Increasing VFA and VFA/SFA ratio were associated with reduced lymph node retrieval (P = 0.03 and P = 0.009, respectively). The association between increasing VFA/SFA ratio with delayed resumption of oral intake (P = 0.05) and prolonged overall survival (P = 0.003) were also significant. Increasing BMI was associated with improved overall (P = 0.02) but not disease-free survival (P = 0.14).

CONCLUSION:

Visceral obesity, measured by VFA/SFA ratio, is a better predictor of postoperative, oncologic, and survival outcomes after TME for rectal adenocarcinoma than general obesity measured by the BMI.

PMID: 21751219 [PubMed – indexed for MEDLINE]

Recent Medical Articles

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Pregnancy following ovarian drilling in a woman with polycystic ovary syndrome

Ballian N, Mantoudis E, Kaltsas GA. Arch Gynecol Obstet. 2006 Mar;273(6):384-6. Epub 2005 Sep 30. Renal Transplant Unit, Laiko Hospital, 17 Agiou Thoma street, Athens, 11527, Greece. Abstract CASE REPORT: We report a woman with a history of polycystic ovary syndrome (PCOS) and nine first-trimester miscarriages following ovulation induction and in vitro fertilization. The majority of these attempts were associated with ovarian hyperstimulation syndrome. No causes of recurrent miscarriages other than PCOS were found. Following laparoscopic ovarian drilling (LOD) she delivered a live neonate at 30 weeks of gestation. DISCUSSION: This case describes the difficulties associated with the management of patients with PCOS and recurrent abortions. We believe that LOD has helped prevent miscarriage in this patient. The early application of this technique in such patients needs to be formally assessed by a prospective study. PMID: 16195901 [PubMed – indexed for MEDLINE]

Somatostatin and its receptors in the development…

Ballian N, Brunicardi FC, Wang XP. Pancreas. 2006 Jul;33(1):1-12. Review. The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA. Abstract The development of the endocrine pancreas is regulated by numerous transcription and growth factors. Somatostatin (SST) is present in many tissues and acts as a neurotransmitter and autocrine/paracrine/endocrine regulator in response to ions, nutrients, peptides, and hormones as well as neurotransmitters. In the pancreas, there is evidence that SST acts an inhibitory paracrine regulator of hormone secretion. Somatostatin receptors (SSTRs) are a family of 5 transmembrane G protein-coupled receptors, which are widely expressed in mammals including humans. SSTRs regulate multiple downstream signal transduction pathways that mediate inhibitory effects. These receptors also exhibit age- and tissue-specific expression patterns. Interactions of SST and SSTRs are not only important during normal pancreas development, but have also been implicated in many pancreatic diseases such as diabetes mellitus and pancreatic cancer. In this review article, we use evidence from recently published animal studies to present the critical roles of SST and SSTRs proteins in the development of the endocrine pancreas. PMID: 16804406 [PubMed – indexed for MEDLINE]

Cytotoxic gene therapy for human breast cancer in vitro…

Levy S, Zhou B, Ballian N, Li Z, Liu SH, Feanny M, Wang XP, Blanchard DK, Brunicardi FC. J Surg Res. 2006 Nov;136(1):154-60. Epub 2006 Sep 27. The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA. cbrunica@bcm.tmc.edu Abstract BACKGROUND: Transcription factor PDX-1 is expressed by human pancreatic and breast cancers. Although cytotoxicity of PDX-1-directed RIP-TK/GCV gene therapy to pancreatic cancer cells has been demonstrated, the efficacy of this treatment in breast cancer cells is unknown. The purpose of this study was to determine the expression of PDX-1 and its effect on RIP activation in two human breast cancer cell lines, AU565 and T47D. We also investigated the efficacy of RIP-TK/GCV gene therapy and examined whether exogenous PDX-1 to would enhance its cytotoxic effect. MATERIALS AND METHODS: RT-PCR was used to determine PDX-1 expression. Gene constructs RSVLacZ and RIPLacZ were used for transient transfection and LacZ expression was determined using reporter assays. T47D cells were also transfected with adenoviral vectors. Cells were transfected with RIP-TK and the suboptimal level of GCV was determined for each cell line. Following GCV treatment, cytotoxicity was measured using MTS assays. The effect of exogenous PDX-1 on LacZ expression and […]

Islet vasculature as a regulator of endocrine pancreas function…

Ballian N, Brunicardi FC. World J Surg. 2007 Apr;31(4):705-14. Review. The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1709 Dryden, Suite 1500, Houston, Texas 77030, USA. Abstract The islets of Langerhans consist of endocrine cells embedded in a network of specialized capillaries that regulate islet blood flow. Despite evidence for a critical role of islet perfusion in endocrine pancreas function, there is information to support no fewer than three models of endocrine cell perfusion, emphasizing the lack of a universally accepted physiological theory. Islet blood flow is regulated by signals, such as hormones and nutrients that reach the islet vasculature from distant tissues via the bloodstream. In addition, islet perfusion determines communication between endocrine and exocrine cells and between different types of endocrine cells within islets. Interest in islet microcirculation has increased after improvements in islet transplantation, a therapy for diabetes mellitus that requires revascularization of grafted islets in a new host organ. Abnormal revascularization is thought to be partly responsible for differences in graft and native islet function. Similarly, angiogenesis has been shown to be a critical step in the transformation of islet hyperplasia to neoplasia. PMID: 17347899 [PubMed – indexed for MEDLINE]

Effective ablation of pancreatic cancer cells in SCID…

Liu SH, Davis A, Li Z, Ballian N, Davis E, Wang XP, Fisher W, Brunicardi FC. J Surg Res. 2007 Jul;141(1):45-52. Epub 2007 May 18. Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA. Abstract BACKGROUND: Studies have demonstrated that adenovirus subtype 5 mediated rat insulin promoter directed thymidine kinase (A-5-RIP-TK)/ganciclovir (GCV) gene therapy resulted in significant enhanced cytotoxicity to both PANC-1 and MIA PaCa2 pancreatic cancer cells in vitro. However, little is known about the effect in vivo. In this study we examine the in vivo safety and efficacy of intravenous A-5-RIP-TK/GCV gene therapy. MATERIALS AND METHODS: 1 x 10(6) Mia PaCa2 cells were injected intraperitoneally (i.p.) into SCID mice to create a mouse model of human pancreatic cancer. A-5-RIP-TK gene construct was administered intravenously (i.v.), followed by i.p. GCV administration. Intravenous injection of A-5-RIP-lacZ reporter gene constructs was used for evaluation of Ad-RIP-gene expression in tumors and other tissues. Optimal adenoviral and GCV doses and treatment duration were determined. Tumor volume, serum insulin, and glucose levels were measured. Immunohistochemical staining of pancreata and tumors were performed to assess morphology and hormone expression and apoptotic rates were determined. RESULTS: All A-5-RIP-TK/GCV-treated mice had reduced […]

Hypophysitis superimposed on a non-functioning pituitary…

Ballian N, Chrisoulidou A, Nomikos P, Samara C, Kontogeorgos G, Kaltsas GA. J Endocrinol Invest. 2007 Sep;30(8):677-83. Department of Surgery, The University of Wisconsin Hospital and Clinics, 600 Highland Avenue, Madison, WI 53792, USA. nballian@uwhealth.org Abstract Pituitary adenomas are common neoplasms requiring medical and/or surgical treatment when associated with hormonal hypersecretion. Treatment of non-functioning pituitary adenomas is necessary when symptoms of mass effect or hormonal deficits occur. However, therapeutic options, including surgical resection and/or radiotherapy, can be associated with significant complications. Hence, it is important to consider disorders that could present in a similar manner to pituitary adenomas, for which surgery is not the indicated therapeutic approach. We describe herein a 38-yr-old woman who presented with a pituitary lesion that was considered to be a non-functioning pituitary adenoma. Due to lack of hormonal deficits and/or compression of adjacent structures, we opted for conservative management and followup with consecutive magnetic resonance imaging. Fifteen months after initial diagnosis, considerable enlargement of the lesion was noted, extending mainly superiorly and indenting the optic chiasm. Repeated endocrine investigation revealed partial anterior pituitary insufficiency. The patient underwent trans-sphenoidal resection of the pituitary lesion; histology revealed a null cell pituitary adenoma and lymphocytic hypophysitis (LYH) of […]

Proliferation, hyperplasia, neogenesis, and neoplasia in the islets of Langerhans…

Ballian N, Hu M, Liu SH, Brunicardi FC. Pancreas. 2007 Oct;35(3):199-206. Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA. Abstract Pancreatic disease is responsible for significant morbidity and mortality as a result of pancreatic carcinoma and diabetes mellitus. Regulation of endocrine cell mass is thought to have a central role in the pathogenesis of both these diseases. Islet cell proliferation, hypertrophy, neogenesis, and apoptosis are the main determinants of endocrine cell mass in the pancreas, and their understanding has been improved by new clues of their genetic and molecular basis. Beta cells have attracted most research interest because of potential implications in the treatment of diabetes mellitus and hypoglycemic disorders. The processes that operate during pancreatic adaptation to a changing hormonal milieu are important in pancreatic carcinogenesis. There is evidence that somatostatin and its receptors are fundamental regulators of endocrine cell mass and are involved in islet tumorigenesis. PMID: 17895838 [PubMed – indexed for MEDLINE]

PDX-1 expression is associated with islet proliferation in vitro and in vivo…

Feanny MA, Fagan SP, Ballian N, Liu SH, Li Z, Wang X, Fisher W, Brunicardi FC, Belaguli NS. J Surg Res. 2008 Jan;144(1):8-16. Epub 2007 Jun 20. The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA. Abstract BACKGROUND: Transcription factor pancreatic duodenal homeobox-1 (PDX-1) is critical for beta-cell differentiation and insulin gene expression. In this study, we investigated the role of PDX-1 in ductal-to-islet cell transdifferentiation, islet cell apoptosis, and proliferation in addition to other regulators associated with these processes in two developing beta-cell models. MATERIALS AND METHODS: CAPAN-1 cells were cultured with the GLP-1 analogue Exendin-4 (Ex-4) to induce transdifferentiation to an insulin-producing phenotype. Expression patterns of PDX-1, somatostatin receptors (SSTR) 1, 2, and 5, p27, and p38 were analyzed. To model pancreatic regeneration in vivo, subtotal pancreatectomies were performed in rats and remnant pancreata were compared to sham laparotomy controls to determine islet size, morphology, apoptosis, and PDX-1 expression. RESULTS: In Ex-4-treated cells, PDX-1 expression increased 67% above basal levels within 24 h and was followed by a 10-fold decline in expression by the end of the study. Expression of cell-cycle inhibitor p27 was down-regulated by 81% at 24 h, while levels […]

PDX-1 acts as a potential molecular target for treatment of human pancreatic cancer…

Liu S, Ballian N, Belaguli NS, Patel S, Li M, Templeton NS, Gingras MC, Gibbs R, Fisher W, Brunicardi FC. Pancreas. 2008 Aug;37(2):210-20. doi: 10.1097/MPA.0b013e31816a4a33. Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA. Abstract OBJECTIVES: The purpose of this study was to investigate whether pancreatic and duodenal homeobox factor 1 (PDX-1) could serve as a potential molecular target for the treatment of pancreatic cancer. METHODS: Cell proliferation, invasion capacity, and protein levels of cell cycle mediators were determined in human pancreatic cancer cells transfected with mouse PDX-1 (mPDX-1) alone or with mPDX-1 short hairpin RNA (shRNA) and/or human PDX-1 shRNA (huPDX-1 shRNA). Tumor cell growth and apoptosis were also evaluated in vivo in PANC-1 tumor-bearing severe combined immunodeficient mice receiving multiple treatments of intravenous liposomal huPDX-1 shRNA. RESULTS: mPDX-1 overexpression resulted in the significant increase of cell proliferation and invasion in MIA PaCa2, but not PANC-1 cells. This effect was blocked by knocking down mPDX-1 expression with mPDX-1 shRNA. Silencing of huPDX-1 expression in PANC-1 cells inhibited cell proliferation in vitro and suppressed tumor growth in vivo which was associated with increased tumor cell apoptosis. PDX-1 overexpression resulted in dysregulation of the cell cycle […]

Transcription factor PDX-1 in human colorectal adenocarcinoma: a potential tumor marker

Ballian N, Liu SH, Brunicardi FC. World J Gastroenterol. 2008 Oct 14;14(38):5823-6. The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA. Abstract AIM: To examine the expression of pancreatic duodenal homeobox-1 (PDX-1) transcription factor in human colorectal cancer. METHODS: RT-PCR, Western blotting, and immuno-histochemistry were performed to determine the expression pattern of transcription factor PDX-1 in primary colorectal tumor, hepatic metastasis, and benign colon tissue from a single patient. RESULTS: The highest PDX-1 transcription levels were detected in the metastasis material. Lower levels of PDX-1 were found to be present in the primary tumor, while normal colon tissue failed to express detectable levels of PDX-1. Western blot data revealed a PDX-1 expression pattern identical to that of mRNA expression. Immunohistochemistry confirmed high metastasis PDX-1 expression, lower levels in the primary tumor, and the presence of only traces of PDX-1 in normal colon tissue. CONCLUSION: These data argue for further evaluation of PDX-1 as a biomarker for colorectal cancer. PMID: 18855980 [PubMed – indexed for MEDLINE] PMCID: PMC2751891

Colonoscopic findings and tumor site do not predict …

Ballian N, Mahvi DM, Kennedy GD. Oncologist. 2009 Jun;14(6):580-5. doi: 10.1634/theoncologist.2008-0271. Epub 2009 May 22. Department of Surgery, University of Wisconsin, G4/701 Clinical Science Center, 600 Highland Avenue, Madison, Wisconsin 53792-7375, USA. Abstract BACKGROUND: In the absence of symptoms related to their primary tumor, patients with stage IV colorectal cancer can undergo medical treatment with their primary tumor in situ. In these patients, bowel obstruction is the most common primary tumor-related complication. We hypothesized that left-sided, circumferential, near-obstructing lesions and/or inability to advance the colonoscope beyond the primary tumor are associated with symptomatic bowel obstruction and are indications for prophylactic primary tumor resection (PTR) or colonic diversion. PATIENTS AND METHODS: The medical oncology database of the University of Wisconsin Hospital was retrospectively reviewed. Inclusion criteria were presentation with stage IV colorectal cancer without previous treatment. Student’s t-test and Fisher’s exact test were used to compare continuous and noncontinuous variables, respectively. RESULTS: Forty-nine patients met the inclusion criteria. None underwent colonic diversion or stenting during the course of their disease. At presentation, nine patients underwent PTR for obstructive symptoms. Forty percent of patients with high-risk colonoscopic lesions required PTR at presentation, compared with 3% of patients without high-risk findings. No patients […]

Colonoscopic findings and tumor site do not predict …

A simplified prognostic system for resected pancreatic neuroendocrine neoplasms…

Ballian N, Loeffler AG, Rajamanickam V, Norstedt PA, Weber SM, Cho CS. HPB (Oxford). 2009 Aug;11(5):422-8. doi: 10.1111/j.1477-2574.2009.00082.x. Section of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792-7375, USA. Abstract BACKGROUND: A number of prognostically relevant clinicopathological variables have been proposed for pancreatic neuroendocrine neoplasms. However, a standardized prognostication system has yet to be established for patients undergoing potentially curative tumour resection. METHODS: We examined a prospectively maintained, single-institution database to identify patients who underwent potentially curative resection of non-metastatic primary pancreatic neuroendocrine neoplasms. Patient, operative and pathological characteristics were analysed to identify variables associated with disease-specific and disease-free survival. RESULTS: Between 1991 and 2007, 43 patients met inclusion criteria. After a median follow-up of 68 months, 5-year disease-specific survival was 94% and 5-year disease-free survival was 72%. Tumours sized > or = 5 cm and vascular invasion were associated with worse disease-specific survival. Tumours sized > or = 5 cm, nodal metastases, positive resection margins and perineural invasion were associated with worse disease-free survival. A scoring system consisting of tumour size > or = 5 cm, histological grade, nodal metastases and resection margin positivity (SGNM) permitted stratification of disease-specific (P= 0.006) and disease-free […]

Revisiting adrenal mass size as an indication for adrenalectomy…

Ballian N, Adler JT, Sippel RS, Chen H. J Surg Res. 2009 Sep;156(1):16-20. doi: 10.1016/j.jss.2009.03.071. Epub 2009 May 3. Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI 53792-7375, USA. Abstract BACKGROUND: Diagnostic tests that can accurately differentiate between benign and malignant adrenal lesions are lacking. Mass size is currently utilized as an indication for adrenalectomy in patients with adrenal masses. However, the accuracy of this criterion and the ideal size threshold are unclear. The aim of the present study was to determine the frequency of using mass size as the only indication for adrenalectomy and the ideal size threshold for distinguishing malignant primary adrenal tumors from lesions that do not require surgical resection. PATIENTS AND METHODS: The adrenalectomy database of the University of Wisconsin was retrospectively reviewed. Patients undergoing adrenalectomy for adrenal mass lesions were identified. Student’s t-test and Fisher’s exact test were used to compare continuous and noncontinuous variables respectively, with P< or =0.05 representing significance. RESULTS: Of 198 adrenalectomies performed between 1989 and 2007, 106 met inclusion criteria. There were no differences in age or gender distribution between patients with malignant and benign lesions. After complete clinical, imaging, and biochemical evaluation, mass size was the […]

Routine evaluation of the distal colon remnant…

Ballian N, Zarebczan B, Munoz A, Harms B, Heise CP, Foley EF, Kennedy GD. J Gastrointest Surg. 2009 Dec;13(12):2260-7. doi: 10.1007/s11605-009-0987-3. Epub 2009 Sep 2. Department of Surgery, University of Wisconsin, G4/701 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-7375, USA. Abstract BACKGROUND: Reversal of Hartmann’s is a common surgical procedure. Routine preoperative evaluation of the distal colonic/rectal remnant (DCRR) with contrast and/or endoscopic studies is frequently performed despite lack of evidence to support this practice. We hypothesize that asymptomatic patients can safely undergo Hartmann’s reversal without preoperative DCRR evaluation. METHODS: Adult patients undergoing reversal of Hartmann’s at a single institution were retrospectively identified. Operative characteristics and outcomes in patients with and without preoperative DCRR evaluation were compared. RESULTS: Between 1993 and 2008, 203 patients underwent reversal of Hartmann’s at a tertiary referral center. Sixty-eight patients (33%) did not undergo preoperative DCRR evaluation and had comparable demographic characteristics, comorbidities, DCRR length, and perioperative outcomes to 135 patients who underwent preoperative contrast and/or endoscopic studies. After evaluation, 125 (93%) patients had normal findings, seven (5%) patients had abnormal studies that did not impact their management, and three (2%) patients underwent additional procedures. CONCLUSION: Hartmann’s reversal without previous DCRR evaluation is […]

Body mass index does not affect postoperative morbidity…

Ballian N, Yamane B, Leverson G, Harms B, Heise CP, Foley EF, Kennedy GD. Ann Surg Oncol. 2010 Jun;17(6):1606-13. doi: 10.1245/s10434-010-0908-4. Epub 2010 Jan 15. Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. Abstract INTRODUCTION: Obesity adds to the technical difficulty of colorectal surgery and is a risk factor for postoperative complications. We hypothesized that obese patients have increased morbidity and poor oncologic outcomes after proctectomy for rectal adenocarcinoma. METHODS: Adult patients undergoing total mesorectal excision (TME) for rectal adenocarcinoma at a tertiary referral center were retrospectively identified from a prospectively maintained database. Operative characteristics, postoperative complication rates, and oncologic outcomes were compared in patients with BMI > or = 30 kg/m(2) and BMI < 30 kg/m(2). RESULTS: Between 1997 and 2009, 254 patients underwent proctectomy for rectal adenocarcinoma, of whom 27% were obese. There were no significant differences in demographics, comorbidities or preoperative oncologic characteristics between obese and nonobese groups. Patients with BMI > or = 30 kg/m(2) had longer operative times (p = 0.04) and higher intraoperative blood loss (p < 0.001) but comparable postoperative complication rates (p = 0.80), number of lymph nodes retrieved (p = 0.57), margin-negative resections (p […]

Optic neuropathy following radiotherapy for Cushing’s disease…

Ballian N, Androulakis II, Chatzistefanou K, Samara C, Tsiveriotis K, Kaltsas GA. Hormones (Athens). 2010 Jul-Sep;9(3):269-73. Review. Department of Surgery, University of Wisconsin, Madison, WI, USA. Abstract Radiation-induced optic neuropathy is a rare adverse effect of radiotherapy applied for the treatment of pituitary adenomas. We report a patient with a recurrent adrenocorticotrophin secreting pituitary adenoma who received external beam irradiation after failing surgical and medical therapy. Sixteen months after radiotherapy, the patient was presented with declining visual acuity, and radiation-induced optic neuropathy was diagnosed. Despite treatment with glucocorticoids and hyperbaric oxygen, her vision did not improve. The pathophysiology, prevention and treatment of radiation-induced optic neuropathy, including the efficacy of hyperbaric oxygen therapy are reviewed. PMID: 20688625 [PubMed – indexed for MEDLINE]

Glucose metabolism in burn patients: the role of insulin and other endocrine hormones

Ballian N, Rabiee A, Andersen DK, Elahi D, Gibson BR. Burns. 2010 Aug;36(5):599-605. doi: 10.1016/j.burns.2009.11.008. Epub 2010 Jan 13. Review. Department of Surgery, University of Wisconsin, Madison, WI, USA. Abstract Severe burn causes a catabolic response with profound effects on glucose and muscle protein metabolism. This response is characterized by hyperglycemia and loss of muscle mass, both of which have been associated with significantly increased morbidity and mortality. In critically ill surgical patients, obtaining tight glycemic control with intensive insulin therapy was shown to reduce morbidity and mortality and has increasingly become the standard of care. In addition to its well-known anti-hyperglycemic action and reduction in infections, insulin promotes muscle anabolism and regulates the systemic inflammatory response. Despite a demonstrated benefit of insulin administration on the maintenance of skeletal muscle mass, it is unknown if this effect translates to improved clinical outcomes in the thermally injured. Further, insulin therapy has the potential to cause hypoglycemia and requires frequent monitoring of blood glucose levels. A better understanding of the clinical benefit associated with tight glycemic control in the burned patient, as well as newer strategies to achieve and maintain that control, may provide improved methods to reduce the clinical morbidity and […]

Multiple treatment cycles of liposome-encapsulated…

Liu SH, Smyth-Templeton N, Davis AR, Davis EA, Ballian N, Li M, Liu H, Fisher W, Brunicardi FC. Surgery. 2011 Apr;149(4):484-95. doi: 10.1016/j.surg.2010.11.014. Epub 2011 Feb 5. Michael E. DeBakey Department of Surgery, Elkins Pancreas Center, Baylor College of Medicine, Houston, TX 77030, USA. Abstract BACKGROUND: Adenoviral gene therapy has been applied widely for cancer therapy; however, transient gene expression as result of humoral immunoneutralization response to adenovirus limits its effect. The purpose of this study is to determine whether DOTAP:cholesterol liposome could shield adenovirus from neutralizing antibody and permit the use of multiple cycles of intravenous liposome encapsulated serotype 5 adenoviral rat insulin promoter directed thymidine kinase (L-A-5-RIP-TK) with ganciclovir (GCV) to enhance its effect. METHODS: The effect of multiple cycles of systemic L-A-5-RIP-TK/GCV therapy was evaluated in grouped PANC-1 SCID mice treated with different numbers of cycles. Humoral immune response to A-5-RIP-TK or L-A-5-RIP-TK was assessed using C57/B6J mice challenged with adenovirus or liposome adenovirus complex. RESULTS: The minimal residual tumor burden (3.2 ± 0.6 mm(3)) and greatest survival time (153.0 ± 6 days) were obtained in the mice receiving 4 and 3 cycles of therapy, respectively. Toxicity to islet cells associated with RIP-TK/GCV therapy was observed after […]

Clinical value of right hemicolectomy…

Alexandraki KI, Griniatsos J, Bramis KI, Ballian N, Dimitriou N, Giannakakis T, Tsigris C, Felekouras E, Kaltsas GA. J Endocrinol Invest. 2011 Apr;34(4):255-9. doi: 10.3275/7286. Epub 2010 Oct 8. Endocrine Unit, Department of Pathophysiology, Laiko University Hospital, Athens Medical School, Mikras Asias 75, 115 27, Athens, Greece. alexandrakik@endo.gr Abstract BACKGROUND: Appendiceal carcinoids (AC) are usually adequately treated by appendectomy. The European Neuroendocrine Tumours Society (ENETS) has recently reconsidered the previous pathologic criteria to identify patients at high risk of extra-appendiceal disease, who are thought to require right hemicolectomy (RHC). AIM: The aim of this retrospective, observational study was to evaluate previous and currently introduced criteria, in identifying patients with AC in whom RHC is justified. SUBJECTS AND METHODS: Twelve patients who underwent RHC for AC were retrospectively identified. Demographic and follow-up data were collected and appendectomy specimens were reviewed for the presence of indications leading to RHC defined as: tumor diameter ≥2 cm, tumor location at the base, mesoappendiceal extension, mitotic index Ki-67≥2%. RHC specimens were examined to identify evidence of extra-appendiceal disease, remaining and/or metastatic disease. RESULTS: Four patients fulfilled two criteria and 8 one criterion for RHC. Two patients had tumors ≥2.0 cm, 5 located at the base, […]

Visceral obesity is associated with outcomes…

Ballian N, Lubner MG, Munoz A, Harms BA, Heise CP, Foley EF, Kennedy GD. J Surg Oncol. 2012 Mar 15;105(4):365-70. doi: 10.1002/jso.22031. Epub 2011 Jul 12. Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA. Abstract BACKGROUND AND OBJECTIVES: General obesity, measured by the body mass index (BMI), increases the technical difficulty of total mesorectal excision (TME) but does not affect oncologic outcomes. The purpose of this study is to compare visceral and general obesity as predictors of outcomes of TME for rectal adenocarcinoma. METHODS: Adult patients undergoing TME for rectal adenocarcinoma were retrospectively identified. Preoperative computed tomography scans were used to measure abdominal circumference (AC), visceral (VFA), and subcutaneous fat area (SFA). BMI, AC, VFA, SFA, total fat area (TFA, sum of VFA and SFA), and VFA/SFA ratio were examined for association with operative, postoperative, oncologic, and survival outcomes in a univariate analysis model. RESULTS: Between 1999 and 2009, 113 patients met inclusion criteria. Increasing VFA and VFA/SFA ratio were associated with reduced lymph node retrieval (P = 0.03 and P = 0.009, respectively). The association between increasing VFA/SFA ratio with delayed resumption of oral intake (P = 0.05) and prolonged overall survival (P = 0.003) were also significant. Increasing BMI […]

Comparable postoperative morbidity and mortality…

Ballian N, Weisensel N, Rajamanickam V, Foley EF, Heise CP, Harms BA, Kennedy GD. World J Surg. 2012 Oct;36(10):2488-96. doi: 10.1007/s00268-012-1694-x. Department of Surgery, G4/701 Clinical Science Center, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792-7375, USA. balliann@upmc.edu Abstract BACKGROUND: Laparoscopic surgery is safe and effective in the management of common abdominal emergencies. However, there is currently a lack of data about its use for emergency colorectal surgery. We hypothesized that laparoscopy can improve the postoperative outcomes of emergency restorative colon resection. METHODS: Adult patients undergoing emergent open and laparoscopic colon resection with primary anastomosis were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005 to 2008 inclusive. Demographic and operative characteristics, laboratory values, and postoperative outcomes were compared between patients undergoing laparoscopic and open colon resection using univariate analyses, multivariate logistic regression, and propensity score analyses. RESULTS: A total of 341 laparoscopic (9.6 %) and 3211 (90.4 %) open colon resections were included. Patients undergoing laparoscopic surgery had a significantly lower prevalence of co-morbidities and better postoperative outcomes. On multivariate analysis, laparoscopic surgery was an independent predictor of a longer operating time (p < 0.001) and shorter total (p = […]

Predictors of mortality after emergent surgery…

Ballian N, Rajamanickam V, Harms BA, Foley EF, Heise CP, Greenberg CC, Kennedy GD. J Trauma Acute Care Surg. 2013 Feb;74(2):611-6. doi: 10.1097/TA.0b013e31827d5d93. Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53792-7375, USA. Abstract BACKGROUND: The surgical treatment of acute colonic diverticulitis is associated with significant morbidity and mortality. However, patient and operative characteristics associated with mortality in this patient population are unclear. We hypothesize that demographic and perioperative variables can be used to predict postoperative mortality.The purpose of this study was to identify perioperative variables predictive of postoperative mortality after emergent surgery for acute diverticulitis. METHODS: Patients with diverticulitis undergoing colostomy and/or partial colectomy with or without primary anastomosis were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database for years 2005 to 2008 inclusive. Only patients undergoing emergent surgery for acute diverticulitis were included. Univariate analyses were performed to compare demographic characteristics, preoperative laboratory values, comorbidities, and intraoperative variables. Variables with a significant (p < 0.10) difference between survivors and nonsurvivors were included in a stepwise logistic regression model to determine predictors of 30-day mortality. Concordance indices (c indices) for postoperative mortality were calculated using 2005 to 2008 […]

A clinical prediction rule for perioperative mortality…

Ballian N, Luketich JD, Levy RM, Awais O, Winger D, Weksler B, Landreneau RJ, Nason KS. J Thorac Cardiovasc Surg. 2013 Mar;145(3):721-9. doi: 10.1016/j.jtcvs.2012.12.026. Epub 2013 Jan 11. Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburg, PA, USA. Abstract OBJECTIVE: In the current era, giant paraesophageal hernia repair by experienced minimally invasive surgeons has excellent perioperative outcomes when performed electively. However, nonelective repair is associated with significantly greater morbidity and mortality, even when performed laparoscopically. We hypothesized that clinical prediction tools using pretreatment variables could be developed that would predict patient-specific risk of postoperative morbidity and mortality. METHODS: We assessed 980 patients who underwent giant paraesophageal hernia repair (1997-2010; 80% elective and 97% laparoscopic). We assessed the association between clinical predictor covariates, including demographics, comorbidity, and urgency of operation, and risk for in-hospital or 30-day mortality and major morbidity. By using forward stepwise logistic regression, clinical prediction models for mortality and major morbidity were developed. RESULTS: Urgency of operation was a significant predictor of mortality (elective 1.1% [9/778] vs nonelective 8% [16/199]; P < .001) and major morbidity (elective 18% [143/781] vs nonelective 41% [81/199]; P < .001). The most common adverse outcomes were […]

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Nikiforos Ballian MBBS, FACS, General Surgeon

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