Journal of the American College of Radiology : JACR, 2015
To compare complications and cost, from a hospital perspective, of chest port insertions performe... more To compare complications and cost, from a hospital perspective, of chest port insertions performed in an interventional radiology (IR) suite versus in surgery in an operating room (OR). This study was approved by an institutional review board and is HIPAA compliant. Medical records were retrospectively searched on consecutive chest port placement procedures, in the IR suite and the OR, between October 22, 2010 and February 26, 2013, to determine patients' demographic information and chest port-related complications and/or infections. A total of 478 charts were reviewed (age range: 21-85 years; 309 women, 169 men). Univariate and bivariate analyses were performed to identify risk factors associated with an increased complication rate. Cost data on 149 consecutive Medicare outpatients (100 treated in the IR suite; 49 treated in the OR) who had isolated chest port insertions between March 2012 and February 2013 were obtained for both the operative services and pharmacy. Nonparametr...
Background Routine resection of falciform ligament and ligamentum teres hepatis (FL-LTH) has been... more Background Routine resection of falciform ligament and ligamentum teres hepatis (FL-LTH) has been advocated in patients undergoing CRS-HIPEC to improve treatment outcomes. While visual examination for disease at the time of CRS-HIPEC may not be reliable, a policy of routine resection may be associated with increased complications. We aimed to study the role of routine FL-LTH resection at the time of CRS-HIPEC. Methods Retrospective review of tumor characteristics and surgical outcomes of patients who underwent CRS-HIPEC from January, 2010 to April, 2013 was conducted. Comparison of visual findings during CRS+HIPEC with pathology of resected specimens was performed. Non-parametric methods were used for analyses. Results CRS-HIPEC was performed in 71 patients (mean age 53.2+14.4 years), of whom FL-LTH resection was performed in 57. The sensitivity of visual examination was 97.4% and the specificity was 75.0%. Visual examination falsely classified 1/33 cases as free of disease (3.0% Fa...
Hepatic artery based therapies (HAT) are offered for patients with unresectable intrahepatic chol... more Hepatic artery based therapies (HAT) are offered for patients with unresectable intrahepatic cholangiocarcinoma (ICC). We aimed to evaluate the comparative effectiveness of HAT -hepatic arterial infusion (HAI), transcatheter arterial chemoembolization (TACE), drug-eluting bead TACE (DEB-TACE), and Yttrium(90) radioembolization (Y-90) for unresectable ICC. A meta-analysis was performed using a prospectively registered search strategy at PROSPERO (CRD42013004830) that utilized PubMed (2003-2013). Primary outcome was median overall survival (OS), and secondary outcomes were tumor response to therapy and toxicity. A total of 20 articles (of 793, n=657 patients) were selected for data extraction. Highest Median OS was observed for HAI (22.8, 95% CI 9.8-35.8) months versus Y90 (13.9, 9.5-18.3) months versus TACE (12.4, 10.9-13.9) months versus DEB-TACE (12.3, 11-13.5) months. Response to therapy (complete and partial) was highest for HAI (56.9%, 95%CI 41.0-72.8) versus Y90 (27.4%, 17.4-37.5) versus TACE (17.3%, 6.8-27.8). The grade III/IV toxicity (Events per patient) was highest for HAI (0.35, 95% CI 0.22-0.48) versus TACE (0.26, 0.21-0.32) versus DEB-TACE (0.32, 0.17-0.48). For patients with unresectable ICC treated with HAT, HAI offered the best outcomes in terms of tumor response and survival but may be limited by toxicity.
HPB : the official journal of the International Hepato Pancreato Biliary Association, 2015
Laparoscopy is recommended to detect radiographically occult metastases in patients with pancreat... more Laparoscopy is recommended to detect radiographically occult metastases in patients with pancreatic cancer before curative resection. This study was conducted to test the hypothesis that diagnostic laparoscopy (DL) is cost-effective in patients undergoing curative resection with or without neoadjuvant therapy (NAT). Decision tree modelling compared routine DL with exploratory laparotomy (ExLap) at the time of curative resection in resectable cancer treated with surgery first, (SF) and borderline resectable cancer treated with NAT. Costs (US$) from the payer's perspective, quality-adjusted life months (QALMs) and incremental cost-effectiveness ratios (ICERs) were calculated. Base case estimates and multi-way sensitivity analyses were performed. Willingness to pay (WtP) was US$4166/QALM (or US$50 000/quality-adjusted life year). Base case costs were US$34 921 for ExLap and US$33 442 for DL in SF patients, and US$39 633 for ExLap and US$39 713 for DL in NAT patients. Routine DL is ...
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 2014
The role of adjuvant radiotherapy in the treatment of ampullary carcinoma (AC) remains unclear. W... more The role of adjuvant radiotherapy in the treatment of ampullary carcinoma (AC) remains unclear. We hypothesized that adjuvant radiotherapy (RT) does not improve survival following resection for AC. The SEER database was queried for patients with non-metastatic AC who underwent surgery (S) from 2004 to 2010. Propensity score (PS) modeling was applied to create balanced cohorts of patients that would be equally likely to receive RT. Cox proportional hazard models were used to compare survival. Of 1,287 patients, 329 (25.6%) received adjuvant RT. Unadjusted median overall survival (OS) for patients receiving adjuvant RT compared to S alone was 27 vs. 36 months (p = 0.14). Patients receiving RT were younger (63 vs. 69 years, p < 0.001), had more advanced tumors (69 vs. 53% T3/T4, p < 0.001), and had more frequent lymph node metastasis (73 vs. 40%, p < 0.001). Adjuvant RT failed to improve both overall survival (27 vs. 29 months, p = 0.58) and disease-specific survival (36 vs. 4...
Due to low life expectancy, treatment strategies for malignant bowel obstruction (MBO) due to per... more Due to low life expectancy, treatment strategies for malignant bowel obstruction (MBO) due to peritoneal carcinomatosis (PC) emphasize improved quality of life and symptom relief. Currently, the value of palliative surgery to treat obstructive PC is unclear. A prospectively registered search strategy (PROSPERO) was utilized to identify articles examining outcomes of patients undergoing surgical palliation for MBO from PC in PubMed (2003-2013). Primary outcomes of interest were median overall survival (OS) and treatment complications. Of 730 articles screened, 64 were selected for full-text review and 5 were quantitatively synthesized. This comprised 313 patients with MBO, of which 249 (79.5%) presented with PC. The mean age was 61.4 years (range 51-67). The OS for surgical patients was 6.4 months (2.8-19.7, n = 190). Stratification by surgical technique suggested an OS of resection, ostomy, and enteral bypass as 7.2 months (n = 174), 3.4 months (n = 9), and 2.7 months (n = 7), respectively. Major complications occurred in 37.0% of patients that underwent resection. This study supports surgical resection over surgical bypass to treat obstructive PC, as it offered better OS with fewer complications. Higher quality studies are needed to conclusively assess the role of surgery in patients with obstructive PC.
Concerns for morbidity after a pancreaticoduodenectomy (PD) has led to practitioners adopting end... more Concerns for morbidity after a pancreaticoduodenectomy (PD) has led to practitioners adopting endoscopic resection or ampullectomy in the treatment of T1 ampullary cancer (AC). It was hypothesized that survival for patients undergoing local resection of AC was inferior to those undergoing a PD. All the data of patients with AC reported in the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2010 were collected. Five-year survival rates according to nodal disease and histological type were compared. There were 1916 cases of AC; 421 (22%) had T1 disease. Among those with T1 disease, 217 (51%) received endoscopic surveillance, 21 (5%) underwent local resection/ampullectomy, 20 (5%) underwent ampullectomy with regional lymphadenectomy and 163 (39%) underwent PD. For patients with complete nodal staging (PD, n = 163), 35 (22%) had metastatic disease in the nodes. Grade was significantly associated with node positivity (P = 0.007). In multivariate models, survival was improved with either an ampullectomy with regional lymphadenectomy [hazard ratio (HR) 0.19; 95% confidence interval (CI) 0.05-0.61, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.005] or a PD (HR 0.23; 95% CI 0.15-0.36, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Patients with T1 AC have a high risk for nodal metastases especially if they are higher-grade lesions. Nodal clearance with a lymphadenectomy or a PD is essential for long-term survival in these patients.
Extra hepatic disease (EHD) is considered a contraindication for hepatic resection for patients w... more Extra hepatic disease (EHD) is considered a contraindication for hepatic resection for patients with colorectal liver metastases (CLRM). A systematic review of the outcomes of hepatic resection in the setting of EHD was undertaken which showed survival rates only slightly inferior to patients with hepatic only disease in this select cohort of patients. Patients with oligometastatic disease and pulmonary metastases had the most favorable outcomes.
The value of immunohistochemistry (IHC)-microarray analysis of pathological specimens in the mana... more The value of immunohistochemistry (IHC)-microarray analysis of pathological specimens in the management of patients is controversial, although preliminary data suggest potential benefit. We describe the characteristics of patients undergoing a commercially available IHC-microarray method in patients with peritoneal metastases (PM) and the feasibility of this technique in this population.
Journal of the American College of Radiology : JACR, 2015
To compare complications and cost, from a hospital perspective, of chest port insertions performe... more To compare complications and cost, from a hospital perspective, of chest port insertions performed in an interventional radiology (IR) suite versus in surgery in an operating room (OR). This study was approved by an institutional review board and is HIPAA compliant. Medical records were retrospectively searched on consecutive chest port placement procedures, in the IR suite and the OR, between October 22, 2010 and February 26, 2013, to determine patients' demographic information and chest port-related complications and/or infections. A total of 478 charts were reviewed (age range: 21-85 years; 309 women, 169 men). Univariate and bivariate analyses were performed to identify risk factors associated with an increased complication rate. Cost data on 149 consecutive Medicare outpatients (100 treated in the IR suite; 49 treated in the OR) who had isolated chest port insertions between March 2012 and February 2013 were obtained for both the operative services and pharmacy. Nonparametr...
Background Routine resection of falciform ligament and ligamentum teres hepatis (FL-LTH) has been... more Background Routine resection of falciform ligament and ligamentum teres hepatis (FL-LTH) has been advocated in patients undergoing CRS-HIPEC to improve treatment outcomes. While visual examination for disease at the time of CRS-HIPEC may not be reliable, a policy of routine resection may be associated with increased complications. We aimed to study the role of routine FL-LTH resection at the time of CRS-HIPEC. Methods Retrospective review of tumor characteristics and surgical outcomes of patients who underwent CRS-HIPEC from January, 2010 to April, 2013 was conducted. Comparison of visual findings during CRS+HIPEC with pathology of resected specimens was performed. Non-parametric methods were used for analyses. Results CRS-HIPEC was performed in 71 patients (mean age 53.2+14.4 years), of whom FL-LTH resection was performed in 57. The sensitivity of visual examination was 97.4% and the specificity was 75.0%. Visual examination falsely classified 1/33 cases as free of disease (3.0% Fa...
Hepatic artery based therapies (HAT) are offered for patients with unresectable intrahepatic chol... more Hepatic artery based therapies (HAT) are offered for patients with unresectable intrahepatic cholangiocarcinoma (ICC). We aimed to evaluate the comparative effectiveness of HAT -hepatic arterial infusion (HAI), transcatheter arterial chemoembolization (TACE), drug-eluting bead TACE (DEB-TACE), and Yttrium(90) radioembolization (Y-90) for unresectable ICC. A meta-analysis was performed using a prospectively registered search strategy at PROSPERO (CRD42013004830) that utilized PubMed (2003-2013). Primary outcome was median overall survival (OS), and secondary outcomes were tumor response to therapy and toxicity. A total of 20 articles (of 793, n=657 patients) were selected for data extraction. Highest Median OS was observed for HAI (22.8, 95% CI 9.8-35.8) months versus Y90 (13.9, 9.5-18.3) months versus TACE (12.4, 10.9-13.9) months versus DEB-TACE (12.3, 11-13.5) months. Response to therapy (complete and partial) was highest for HAI (56.9%, 95%CI 41.0-72.8) versus Y90 (27.4%, 17.4-37.5) versus TACE (17.3%, 6.8-27.8). The grade III/IV toxicity (Events per patient) was highest for HAI (0.35, 95% CI 0.22-0.48) versus TACE (0.26, 0.21-0.32) versus DEB-TACE (0.32, 0.17-0.48). For patients with unresectable ICC treated with HAT, HAI offered the best outcomes in terms of tumor response and survival but may be limited by toxicity.
HPB : the official journal of the International Hepato Pancreato Biliary Association, 2015
Laparoscopy is recommended to detect radiographically occult metastases in patients with pancreat... more Laparoscopy is recommended to detect radiographically occult metastases in patients with pancreatic cancer before curative resection. This study was conducted to test the hypothesis that diagnostic laparoscopy (DL) is cost-effective in patients undergoing curative resection with or without neoadjuvant therapy (NAT). Decision tree modelling compared routine DL with exploratory laparotomy (ExLap) at the time of curative resection in resectable cancer treated with surgery first, (SF) and borderline resectable cancer treated with NAT. Costs (US$) from the payer's perspective, quality-adjusted life months (QALMs) and incremental cost-effectiveness ratios (ICERs) were calculated. Base case estimates and multi-way sensitivity analyses were performed. Willingness to pay (WtP) was US$4166/QALM (or US$50 000/quality-adjusted life year). Base case costs were US$34 921 for ExLap and US$33 442 for DL in SF patients, and US$39 633 for ExLap and US$39 713 for DL in NAT patients. Routine DL is ...
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 2014
The role of adjuvant radiotherapy in the treatment of ampullary carcinoma (AC) remains unclear. W... more The role of adjuvant radiotherapy in the treatment of ampullary carcinoma (AC) remains unclear. We hypothesized that adjuvant radiotherapy (RT) does not improve survival following resection for AC. The SEER database was queried for patients with non-metastatic AC who underwent surgery (S) from 2004 to 2010. Propensity score (PS) modeling was applied to create balanced cohorts of patients that would be equally likely to receive RT. Cox proportional hazard models were used to compare survival. Of 1,287 patients, 329 (25.6%) received adjuvant RT. Unadjusted median overall survival (OS) for patients receiving adjuvant RT compared to S alone was 27 vs. 36 months (p = 0.14). Patients receiving RT were younger (63 vs. 69 years, p < 0.001), had more advanced tumors (69 vs. 53% T3/T4, p < 0.001), and had more frequent lymph node metastasis (73 vs. 40%, p < 0.001). Adjuvant RT failed to improve both overall survival (27 vs. 29 months, p = 0.58) and disease-specific survival (36 vs. 4...
Due to low life expectancy, treatment strategies for malignant bowel obstruction (MBO) due to per... more Due to low life expectancy, treatment strategies for malignant bowel obstruction (MBO) due to peritoneal carcinomatosis (PC) emphasize improved quality of life and symptom relief. Currently, the value of palliative surgery to treat obstructive PC is unclear. A prospectively registered search strategy (PROSPERO) was utilized to identify articles examining outcomes of patients undergoing surgical palliation for MBO from PC in PubMed (2003-2013). Primary outcomes of interest were median overall survival (OS) and treatment complications. Of 730 articles screened, 64 were selected for full-text review and 5 were quantitatively synthesized. This comprised 313 patients with MBO, of which 249 (79.5%) presented with PC. The mean age was 61.4 years (range 51-67). The OS for surgical patients was 6.4 months (2.8-19.7, n = 190). Stratification by surgical technique suggested an OS of resection, ostomy, and enteral bypass as 7.2 months (n = 174), 3.4 months (n = 9), and 2.7 months (n = 7), respectively. Major complications occurred in 37.0% of patients that underwent resection. This study supports surgical resection over surgical bypass to treat obstructive PC, as it offered better OS with fewer complications. Higher quality studies are needed to conclusively assess the role of surgery in patients with obstructive PC.
Concerns for morbidity after a pancreaticoduodenectomy (PD) has led to practitioners adopting end... more Concerns for morbidity after a pancreaticoduodenectomy (PD) has led to practitioners adopting endoscopic resection or ampullectomy in the treatment of T1 ampullary cancer (AC). It was hypothesized that survival for patients undergoing local resection of AC was inferior to those undergoing a PD. All the data of patients with AC reported in the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2010 were collected. Five-year survival rates according to nodal disease and histological type were compared. There were 1916 cases of AC; 421 (22%) had T1 disease. Among those with T1 disease, 217 (51%) received endoscopic surveillance, 21 (5%) underwent local resection/ampullectomy, 20 (5%) underwent ampullectomy with regional lymphadenectomy and 163 (39%) underwent PD. For patients with complete nodal staging (PD, n = 163), 35 (22%) had metastatic disease in the nodes. Grade was significantly associated with node positivity (P = 0.007). In multivariate models, survival was improved with either an ampullectomy with regional lymphadenectomy [hazard ratio (HR) 0.19; 95% confidence interval (CI) 0.05-0.61, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.005] or a PD (HR 0.23; 95% CI 0.15-0.36, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Patients with T1 AC have a high risk for nodal metastases especially if they are higher-grade lesions. Nodal clearance with a lymphadenectomy or a PD is essential for long-term survival in these patients.
Extra hepatic disease (EHD) is considered a contraindication for hepatic resection for patients w... more Extra hepatic disease (EHD) is considered a contraindication for hepatic resection for patients with colorectal liver metastases (CLRM). A systematic review of the outcomes of hepatic resection in the setting of EHD was undertaken which showed survival rates only slightly inferior to patients with hepatic only disease in this select cohort of patients. Patients with oligometastatic disease and pulmonary metastases had the most favorable outcomes.
The value of immunohistochemistry (IHC)-microarray analysis of pathological specimens in the mana... more The value of immunohistochemistry (IHC)-microarray analysis of pathological specimens in the management of patients is controversial, although preliminary data suggest potential benefit. We describe the characteristics of patients undergoing a commercially available IHC-microarray method in patients with peritoneal metastases (PM) and the feasibility of this technique in this population.
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Papers by Thejus Jayakrishnan