Tara Connelly - Academia.edu (original) (raw)

Papers by Tara Connelly

Research paper thumbnail of A dramatic reduction in surgical consults in a University Teaching Hospital during the COVID-19 pandemic

The Surgeon, 2021

Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on ... more Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre-including this research content-immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

Research paper thumbnail of Brown bowel syndrome, an unusual cause of sigmoid volvulus

Journal of Surgical Case Reports

We report a case of a 79-year-old gentleman who presented to the emergency department with a 5-da... more We report a case of a 79-year-old gentleman who presented to the emergency department with a 5-day history of abdominal pain, constipation, a progressively distending abdomen and new onset feculent vomiting on a background of a recent endoscopic decompression of a sigmoid volvulus. Investigations confirmed the presence of a recurrent sigmoid volvulus. Attempts to reduce this endoscopically failed and laparotomy with sub-total colectomy and ileostomy formation was performed. Histology from the resected specimen identified a distinct pathology, namely intestinal lipofuscinosis also known as brown bowel syndrome. Brown bowel syndrome is a recognized but rare complication of chronic long term malnutrition. It may present in a myriad of ways including atonia and, rarely, massive colonic dilatation, as in our case.

Research paper thumbnail of Is a defunctioning ostomy needed in rectal cancer patients undergoing a low anterior resection after neoadjuvant chemoradiation? A National Surgical Quality Improvement Program analysis

Journal of the American College of Surgeons, 2014

Research paper thumbnail of Thymic carcinoma presenting as atypical chest pain

BMJ case reports, 2015

A 58-year-old woman with a 2-month history of atypical chest pain was referred to the chest pain ... more A 58-year-old woman with a 2-month history of atypical chest pain was referred to the chest pain clinic by the general practitioner. Exercise stress test was positive and subsequent coronary angiogram revealed significant triple vessel disease with left ventricular impairment requiring a coronary artery bypass graft (CABG). The patient had a chest X-ray as part of the preoperative work up. Chest X-ray revealed a large anterior mediastinal mass. Subsequent thorax CT revealed a 7.2 cm anterior mediastinal mass. CT-guided biopsy of the mass revealed the diagnosis of a poorly differentiated thymic basaloid carcinoma. The patient was successfully treated with concomitant surgery involving complete resection of the mass and a CABG procedure.

Research paper thumbnail of Circumportal pancreas: a review of the literature and image findings

Surgical and Radiologic Anatomy, 2015

Fused pancreatic tissue encasing the portal and/or superior mesenteric vein, circumportal pancrea... more Fused pancreatic tissue encasing the portal and/or superior mesenteric vein, circumportal pancreas, is a congenital anomaly that has been associated with operative complications in resections involving the head of the pancreas. We describe this anomaly and highlight its pathophysiology and surgical outcomes through a review of the literature to date, drawings and a computed tomography example. A literature search was undertaken using Pubmed and the search terms "circumportal pancreas," "annular pancreas" and "pancreatic anomaly." 91 cases of circumportal pancreas were identified in the literature. The number of reported cases increased with time. 14 were documented as having undergone surgery (11 carcinoma or suspected carcinoma/3 benign neoplasm). Surgical outcome was reported in 13. Five of 13 (38.5 %) experienced a fistula. Three cases were treated with a drain. One incident of potentially unnecessary surgery due to the misidentification of circumportal pancreas was noted. (1) The identification of circumportal pancreas is increasing but is relatively rare. (2) Varying locations of the main pancreatic duct can induce inappropriate construction during pancreaticojejunostomy and can influence the risk of fistula. In the presence of CP, distal pancreatectomy with pancreatic division in front of portal vein creates two sources of pancreatic fistula. (3) The high incidence of associated vascular variants can directly influence pancreatic resection and can affect vascular reconstruction for complete oncologic resection. Therefore, the preoperative location of the main pancreatic duct and presence of any vascular variants in CP must be systematically identified before programed surgery.

Research paper thumbnail of Automated implantable cardioverter defibrillator lead infection in a patient with previous superior vena cava thrombosis

BMJ Case Reports, 2015

We present a case of a 44-year-old woman who presented with cough, pleuritic chest pain and fever... more We present a case of a 44-year-old woman who presented with cough, pleuritic chest pain and fever leading to a diagnosis of pneumonia±pulmonary embolism. She had a history of familial hypertrophic obstructive cardiomyopathy (HOCM), for which an automated implantable cardioverter defibrillator (AICD) had been implanted, and a subsequent superior vena cava (SVC) thrombus, for which she was anticoagulated with warfarin. On admission, blood cultures grew a coagulase-negative Staphylococcus. CT pulmonary angiogram and transoesophageal echocardiography (TOE) were performed and revealed large vegetations adherent to the AICD leads with complete occlusion of the SVC. The infected leads were the source of sepsis. Open surgery was planned. For cardiopulmonary bypass, the venous cannula was inserted in the inferior vena cava (IVC) and a completely bloodless field was obtained in the right atrium allowing for the extraction of the AICD leads completely, along with the adherent vegetations from within.

Research paper thumbnail of Pseudomyxoma peritonei diagnosed 19 years after appendicectomy

BMJ case reports, 2015

Pseudomyxoma peritonei (PMP) is an uncommon clinical finding describing the intraperitoneal accum... more Pseudomyxoma peritonei (PMP) is an uncommon clinical finding describing the intraperitoneal accumulation of abundant mucinous, jelly-like material. This entity may represent a spectrum of diseases ranging from mucinous ascites, commonly associated with ruptured epithelial tumours of the appendix, to frank mucinous carcinomatosis. In cases of appendiceal origin, the patient may present with signs and symptoms of acute appendicitis, and thus careful diagnosis must be made in order to correctly and appropriately guide management. This may include a combination of surgical debulking with or without intraperitoneal or systemic chemotherapy. We present a 52-year-old woman with a 4-month history of abdominal pain and distension with a previous appendicectomy 19 years earlier. Radiological and pathological investigations diagnosed a probable PMP secondary to ruptured appendicitis many years ago. We describe her unique case, with emphasis on length of time to diagnosis and clinical managemen...

Research paper thumbnail of Unicuspid aortic valve presenting with cardiac arrest in an adolescent

BMJ Case Reports, 2015

Unicuspid aortic valve (UAV) is a rare congenital anomaly typically affecting patients in their f... more Unicuspid aortic valve (UAV) is a rare congenital anomaly typically affecting patients in their fourth and fifth decades and presenting with signs of heart failure. Our case is one of a previously asymptomatic teenage girl with a UAV, who presented with cardiac arrest and was successfully treated. Only two other similar cases have been reported in the literature, both were of slightly older male patients. Our case highlights the morbidity associated with the anomaly supporting the need for careful assessment of the valve in cases where UAV is suspected.

Research paper thumbnail of Risk Factors for the Development of an Incisional Hernia After Sigmoid Resection for Diverticulitis: An Analysis of 33 Patient, Operative and Disease-associated Factors

The American surgeon, 2015

Incisional hernia (IH) is a relatively common sequelae of sigmoidectomy for diverticulitis. The a... more Incisional hernia (IH) is a relatively common sequelae of sigmoidectomy for diverticulitis. The aim of this study was to investigate factors that may predict IH in diverticulitis patients. Two hundred and one diverticulitis patients undergoing sigmoidectomy between January 2002 and December 2012 were identified (mean follow-up 5.15 ± 2.33 years). Patients with wound infections were excluded. Thirteen patient-associated, three diverticular disease-related, and 17 operative variables were evaluated in patients with and without IH. Volumetric fat was measured on preoperative CTs. Fischer's exact, χ(2), and Mann-Whitney tests and multivariate regression analysis were used for statistics. Thirty-four (17%) patients had an IH. On multivariate analysis, wound packing (OR 3.4, P = 0.017), postoperative nonwound infection (OR 7.4, P = 0.014), and previous hernia (OR 3.6, P = 0.005) were as independent predictors of IH. Fifteen of 34 (44%) patients who developed a hernia had a history of ...

Research paper thumbnail of Surgical diverticulitis is not associated with defects in the expression of wound healing genes

International journal of colorectal disease, Jan 24, 2015

The development of diverticuli may represent defects in collagen vascular tissue integrity possib... more The development of diverticuli may represent defects in collagen vascular tissue integrity possibly from a genetic predisposition. We evaluated the tissue expression of wound healing genes in sigmoid tissue from youthful patients undergoing surgery for diverticulitis and thus would more likely suffer from a genetic predisposition (SD mean age 39 ± 0.9) versus controls in the form of patients over the age of 50 (mean age 52.9 ± 10.5 years) without evidence of diverticular disease. The mRNA expression of 84 genes associated with the extracellular matrix, cellular adhesion, growth factors, inflammatory cytokines, and signal transduction was evaluated in 16 SD and 15 control tissues using a Qiagen(™) Wound Healing Array. Vitronectin, the gene protein with the highest potential significance on raw analysis, was further investigated using a Taqman assay with an additional 11 SD (total n = 27) and four control (total n = 19) samples. Statistics were by Student's t and Mann-Whitney test...

Research paper thumbnail of Measurement of visceral fat on preoperative computed tomography predicts complications after sigmoid colectomy for diverticular disease

American journal of surgery, Jan 7, 2015

Visceral and subcutaneous abdominal fat parameters have been associated with worse surgical outco... more Visceral and subcutaneous abdominal fat parameters have been associated with worse surgical outcomes in colorectal cancer but have not been investigated in diverticulitis. Volumetric fat parameters were measured on preoperative computed tomography scans from 211 diverticulitis patients. Primary outcome was a serious postoperative complication (Clavien-Dindo grades 2-4). Variables including age, disease duration, American Society of Anesthesiology score, ostomy, immunosuppression, body mass index, and volumetric fat parameters were examined. SPSS was used for statistics. The serious postoperative complication rate was 12.7%. On univariate analysis, several factors including older age (P = .0001), ostomy creation (P = .02), higher visceral fat (VF, P = .01), emergent surgery (P = .05), and higher American Society of Anesthesiology score (P = .05) were associated with complications. On multivariate regression analysis, only VF was independently associated with complications. Diverticul...

Research paper thumbnail of Outcome of open massive rotator cuff repairs with double-row suture knotless anchors: case series

International orthopaedics, Jan 12, 2015

The aim of the present study was to evaluate functional and quality of life outcomes after transo... more The aim of the present study was to evaluate functional and quality of life outcomes after transosseous equivalent (TOE) double row suture technique for massive rotator cuff (RTC) tear repair using validated subjective and objective measures. This technique has shown promising preliminary results in RTC repair; however, a paucity of evidence regarding these outcomes in massive RTC (MRTC) tear repair exists. Patients were identified using the Hospital Inpatient Enquiry Scheme. Pre-operative MRI and medical records were reviewed. A massive RTC tear was defined as the detachment of two or more tendons from their point of insertion on the humeral head. The Constant and Oxford Shoulder Scores (OSS) and SF-12 questionnaire were used for evaluation. Twenty-two patients were studied (72.7 % male; mean age at surgery, 62.6 years). Mean follow up was 14 (range six to 30) months. At six weeks postoperatively, 68 % achieved good or excellent shoulder function as measured by the OSS and Constant...

Research paper thumbnail of Predictors of recurrence of Crohn's disease after ileocolectomy: a review

World journal of gastroenterology : WJG, Jan 21, 2014

Recurrence after ileocolectomy for Crohn's disease (CD) is common and occurs in up to 80% of ... more Recurrence after ileocolectomy for Crohn's disease (CD) is common and occurs in up to 80% of patients. Such recurrence can result in repeated surgical interventions, an increased need for medical treatment and, frequently, an impaired quality of life. The aim of this overview is to provide a summary of the factors associated with disease recurrence after ileocolectomy for CD. Recurrence can be measured clinically or endoscopically using established scoring systems. Radiology and serologic tests can also be used, oftentimes in conjunction with endoscopy and/or clinical findings. Many patient and operative factors as well as pharmacologic treatments have been studied as potential predictors of recurrence. Of these, only smoking and immunomodulatory or biologic medical treatment have repeatedly been shown to effect recurrence. Genetic predictors have been studied and suggested but further evaluation in larger cohorts is necessary. This paper highlights validated, reproducible scori...

Research paper thumbnail of The surgical treatment of inflammatory bowel disease-associated dysplasia

Expert review of gastroenterology & hepatology, 2013

Surgical management of colonic dysplasia discovered in the inflammatory bowel disease patient is ... more Surgical management of colonic dysplasia discovered in the inflammatory bowel disease patient is controversial. Total proctocolectomy (TPC) is the most definitive treatment for the eradication of undiagnosed synchronous dysplasias and/or carcinomas and the prevention of subsequent metachronous lesions in both Crohn's disease (CD) and ulcerative colitis (UC). However, TPC is not always an attractive option owing to patient comorbidities and patient preference. Historically, dysplasia has been most studied in patients with UC, where the option of reconstruction without a stoma makes TPC more acceptable. Due to a relative lack of research on CD-related dysplasia, surveillance and treatment of CD dysplasia has followed paradigms based on UC data. However, due to pathophysiological differences in CD versus UC, options for surgical management in CD may be more varied than simple TPC, particularly in the less healthy surgical candidate and those who refuse end ileostomy.

Research paper thumbnail of TNFSF15 mRNA Expression Is Upregulated in Sigmoid Tissue of Diverticulitis Patients

Journal of the American College of Surgeons, 2014

Research paper thumbnail of Genetic Determinants Associated With Early Age of Diagnosis of IBD

Diseases of the Colon & Rectum, 2015

Inflammatory bowel disease (IBD) is typically diagnosed at 20 to 40 years of age. However, very y... more Inflammatory bowel disease (IBD) is typically diagnosed at 20 to 40 years of age. However, very young versus elderly patients with IBD may have different mechanisms of disease that may affect prognosis and care. The purpose of this work was to identify single nucleotide polymorphisms associated with age of onset of Crohn's disease and ulcerative colitis. Patients were genotyped using a custom microarray chip containing 332 IBD-associated single nucleotide polymorphisms. Age at diagnosis as a continuous variable was assessed using linear regression. Patients were then subgrouped by age at diagnosis and compared by the Fisher exact test. Bonferroni correction was used in all of the analyses. This study was conducted at a tertiary academic hospital. Sixty patients with Crohn's disease and 26 with ulcerative colitis were ≤ 16 years old, 259 patients with Crohn's disease and 248 with ulcerative colitis were 17-60 years old, and 10 patients with Crohn's disease and 20 with ulcerative colitis were >60 years old at diagnosis and included in this study. Age at diagnosis and single nucleotide polymorphism correlations were measured in this study. The NOD2 single nucleotide polymorphism rs2076756 was associated with younger age at Crohn's disease diagnosis (p = 0.0002). Patients with the AA/wild-type genotype were diagnosed at 31.9 ± 1.23 years, AG heterozygotes at 25.6 ± 0.99 years, and GG/at-risk allele homozygotes at 22.6 ± 1.32 years. Depending on age categories compared, single nucleotide polymorphisms in POU5F1, TNFSF15, and HLA DRB1*501 were associated with age of Crohn's disease diagnosis. No genetic associations were seen between ulcerative colitis and linear age at diagnosis; however, the G allele of the LAMB1 single nucleotide polymorphism rs886774 was found to be associated with ulcerative colitis diagnosed at ≤ 16 versus >17 years old (p = 0.008). This study was limited to known IBD single nucleotide polymorphisms. This analysis reaffirms the association between NOD2, a molecule of innate immunity, and early Crohn's disease onset. This is the first report of a possible association between early Crohn's disease and the POU5F1, TNFSF15, and HLA DRB1*501 genes. The LAMB1 gene, associated with mucosal basement membrane integrity, was associated with early onset ulcerative colitis and, thus, suggests a fundamentally different mechanism of early disease pathogenesis in ulcerative colitis versus Crohn's disease.

Research paper thumbnail of Organ space infection after ileocolectomy for Crohn's disease: a National Surgical Quality Improvement Project study

Organ space infection (OSI) rates post ileocolectomy for Crohn&am... more Organ space infection (OSI) rates post ileocolectomy for Crohn's disease are relatively high. The aim of this study was to determine which factors predispose to OSI in this patient cohort. Data for 2,618 Crohn's patients undergoing ileocolectomy between 2005 and 2011 were obtained from the American College of Surgeons National Surgical Quality Improvement Project database. Primary outcome was an OSI within 30 days of discharge. Univariate analysis using chi-square and Student t tests and a logistic multivariate analysis were performed. Preoperative weight loss (odds ratio [OR] 2.11, P = .002), extended operating time (OR 1.57, P = .016), open procedures (OR 1.47, P = .043), and contaminated/dirty wounds (OR 1.95, P = .008) conferred an increased risk for OSI on multivariate analysis. Rates of stoma creation and steroid use were not significantly different between the groups. Weight loss is a preoperative, potentially modifiable variable associated with OSI in Crohn's patients undergoing ileocolectomy and OSI-associated operative factors which may be noted to identify high-risk patients include extended operating time and open procedures.

Research paper thumbnail of An interleukin-4 polymorphism is associated with susceptibility to Clostridium difficile infection in patients with inflammatory bowel disease: Results of a retrospective cohort study

Surgery, 2014

Background. Clinical studies have suggested that patients with inflammatory bowel disease (IBD) a... more Background. Clinical studies have suggested that patients with inflammatory bowel disease (IBD) are at greater risk for developing Clostridium difficile infection (CDI). The purpose of this study was to identify single-nucleotide polymorphisms (SNPs) associated with CDI among IBD patients.

Research paper thumbnail of Ulcerative colitis neoplasia is not associated with common inflammatory bowel disease single-nucleotide polymorphisms

Surgery, 2014

Background. Neoplasia complicating ulcerative colitis (UC-neoplasia) is a problem that is poorly ... more Background. Neoplasia complicating ulcerative colitis (UC-neoplasia) is a problem that is poorly addressed by present surveillance techniques. The association of greater than 300 single nucleotide polymorphisms (SNPs) with inflammatory bowel disease (IBD) suggests the possibility that certain genetic polymorphisms might identify patients with UC destined for malignant degeneration. This present study tested the hypothesis that presently known IBD-associated SNPs may correlate with UC-neoplasia. Materials and methods. A total of 41 patients with UC-neoplasia (mean age 56 ± 2.1 years) were identified from our divisional IBD Biobank (low-grade dysplasia n = 13, high-grade dysplasia n = 8, colorectal cancer [CRC] n = 20). These patients were individually age, sex, and disease duration matched with UC patients without neoplasia. Primary sclerosing cholangitis and family history of CRC were recorded. Patients were genotyped for 314 of the most commonly IBD-associated SNPs by a custom SNP microarray. Logistic regression and Fischer exact test were used for statistical analysis. Results. After Bonferroni correction, none of the 314 IBD-associated SNPs correlated with UC-neoplasia when compared with matched UC controls. The incidence of primary sclerosing cholangitis was greater in the UC-neoplasia group (10/41, 24% vs 3/41, 7%; P = .03) compared with UC controls. The severity of neoplasia (low grade dysplasia versus high grade dysplasia versus CRC) correlated with disease duration (7.9 vs 13.4 vs 20.7 years, respectively). Conclusion. The lack of correlation between well-known IBD-associated SNPs and UC-neoplasia demonstrated in this study suggests that the development of neoplasia in patients with UC is associated with genetic determinants other than those that predispose to inflammation or results from posttranslational modifications or epigenetic factors rather than germline polymorphisms. (Surgery 2014;156:253-62.)

Research paper thumbnail of Increased Risk of Incisional Hernia after Sigmoid Colectomy for Diverticulitis Compared with Colon Cancer

Journal of the American College of Surgeons, 2014

We aimed to determine if an increased incidence of incisional hernias is present in patients unde... more We aimed to determine if an increased incidence of incisional hernias is present in patients undergoing sigmoidectomy for diverticulitis vs cancer. The pathophysiology of diverticulitis is poorly understood, but might involve a collagen vascular abnormality that can predispose to incisional hernia. In this IRB-approved, retrospective study, patients who underwent sigmoid colectomies for diverticulitis or cancer between January 2003 and September 2012 were studied. Exclusion criteria included the development of surgical site infections and neoadjuvant chemoradiotherapy. A multivariate logistic regression was used with covariate adjustments for known risk factors for hernia development. Four hundred forty-two patients (mean age 59.3 ± 13.9 years) with a median follow-up of 30 months were analyzed. The incidence of incisional hernia was 15.1% in diverticulitis patients vs 5.8% in the cancer cohort (41 of 271 vs 10 of 171; p = 0.003). Univariate analysis of risk factors associated with postoperative incisional hernia included steroid use (p = 0.007), wound packing (p = 0.001), higher American Society of Anesthesiologists classification (p = 0.001), absorbable suture closure (p = 0.02), blood transfusion (p = 0.04), stoma formation (p = 0.02), increased body mass index (p = 0.008), and history of incisional hernia (p = 0.00008). Multivariate logistic regression demonstrated a persistent association between diverticulitis and hernia development (p = 0.01). Odds of a hernia developing after sigmoidectomy for diverticulitis were 2.82 times greater than in the cancer cohort (95% CI, 1.3-6.6). The incidence of an incisional hernia developing after a sigmoid colectomy is significantly higher when performed for diverticulitis as compared with cancer. This might be due to a connective tissue disorder, which predisposes to development of both diverticula and hernias.

Research paper thumbnail of A dramatic reduction in surgical consults in a University Teaching Hospital during the COVID-19 pandemic

The Surgeon, 2021

Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on ... more Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre-including this research content-immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

Research paper thumbnail of Brown bowel syndrome, an unusual cause of sigmoid volvulus

Journal of Surgical Case Reports

We report a case of a 79-year-old gentleman who presented to the emergency department with a 5-da... more We report a case of a 79-year-old gentleman who presented to the emergency department with a 5-day history of abdominal pain, constipation, a progressively distending abdomen and new onset feculent vomiting on a background of a recent endoscopic decompression of a sigmoid volvulus. Investigations confirmed the presence of a recurrent sigmoid volvulus. Attempts to reduce this endoscopically failed and laparotomy with sub-total colectomy and ileostomy formation was performed. Histology from the resected specimen identified a distinct pathology, namely intestinal lipofuscinosis also known as brown bowel syndrome. Brown bowel syndrome is a recognized but rare complication of chronic long term malnutrition. It may present in a myriad of ways including atonia and, rarely, massive colonic dilatation, as in our case.

Research paper thumbnail of Is a defunctioning ostomy needed in rectal cancer patients undergoing a low anterior resection after neoadjuvant chemoradiation? A National Surgical Quality Improvement Program analysis

Journal of the American College of Surgeons, 2014

Research paper thumbnail of Thymic carcinoma presenting as atypical chest pain

BMJ case reports, 2015

A 58-year-old woman with a 2-month history of atypical chest pain was referred to the chest pain ... more A 58-year-old woman with a 2-month history of atypical chest pain was referred to the chest pain clinic by the general practitioner. Exercise stress test was positive and subsequent coronary angiogram revealed significant triple vessel disease with left ventricular impairment requiring a coronary artery bypass graft (CABG). The patient had a chest X-ray as part of the preoperative work up. Chest X-ray revealed a large anterior mediastinal mass. Subsequent thorax CT revealed a 7.2 cm anterior mediastinal mass. CT-guided biopsy of the mass revealed the diagnosis of a poorly differentiated thymic basaloid carcinoma. The patient was successfully treated with concomitant surgery involving complete resection of the mass and a CABG procedure.

Research paper thumbnail of Circumportal pancreas: a review of the literature and image findings

Surgical and Radiologic Anatomy, 2015

Fused pancreatic tissue encasing the portal and/or superior mesenteric vein, circumportal pancrea... more Fused pancreatic tissue encasing the portal and/or superior mesenteric vein, circumportal pancreas, is a congenital anomaly that has been associated with operative complications in resections involving the head of the pancreas. We describe this anomaly and highlight its pathophysiology and surgical outcomes through a review of the literature to date, drawings and a computed tomography example. A literature search was undertaken using Pubmed and the search terms "circumportal pancreas," "annular pancreas" and "pancreatic anomaly." 91 cases of circumportal pancreas were identified in the literature. The number of reported cases increased with time. 14 were documented as having undergone surgery (11 carcinoma or suspected carcinoma/3 benign neoplasm). Surgical outcome was reported in 13. Five of 13 (38.5 %) experienced a fistula. Three cases were treated with a drain. One incident of potentially unnecessary surgery due to the misidentification of circumportal pancreas was noted. (1) The identification of circumportal pancreas is increasing but is relatively rare. (2) Varying locations of the main pancreatic duct can induce inappropriate construction during pancreaticojejunostomy and can influence the risk of fistula. In the presence of CP, distal pancreatectomy with pancreatic division in front of portal vein creates two sources of pancreatic fistula. (3) The high incidence of associated vascular variants can directly influence pancreatic resection and can affect vascular reconstruction for complete oncologic resection. Therefore, the preoperative location of the main pancreatic duct and presence of any vascular variants in CP must be systematically identified before programed surgery.

Research paper thumbnail of Automated implantable cardioverter defibrillator lead infection in a patient with previous superior vena cava thrombosis

BMJ Case Reports, 2015

We present a case of a 44-year-old woman who presented with cough, pleuritic chest pain and fever... more We present a case of a 44-year-old woman who presented with cough, pleuritic chest pain and fever leading to a diagnosis of pneumonia±pulmonary embolism. She had a history of familial hypertrophic obstructive cardiomyopathy (HOCM), for which an automated implantable cardioverter defibrillator (AICD) had been implanted, and a subsequent superior vena cava (SVC) thrombus, for which she was anticoagulated with warfarin. On admission, blood cultures grew a coagulase-negative Staphylococcus. CT pulmonary angiogram and transoesophageal echocardiography (TOE) were performed and revealed large vegetations adherent to the AICD leads with complete occlusion of the SVC. The infected leads were the source of sepsis. Open surgery was planned. For cardiopulmonary bypass, the venous cannula was inserted in the inferior vena cava (IVC) and a completely bloodless field was obtained in the right atrium allowing for the extraction of the AICD leads completely, along with the adherent vegetations from within.

Research paper thumbnail of Pseudomyxoma peritonei diagnosed 19 years after appendicectomy

BMJ case reports, 2015

Pseudomyxoma peritonei (PMP) is an uncommon clinical finding describing the intraperitoneal accum... more Pseudomyxoma peritonei (PMP) is an uncommon clinical finding describing the intraperitoneal accumulation of abundant mucinous, jelly-like material. This entity may represent a spectrum of diseases ranging from mucinous ascites, commonly associated with ruptured epithelial tumours of the appendix, to frank mucinous carcinomatosis. In cases of appendiceal origin, the patient may present with signs and symptoms of acute appendicitis, and thus careful diagnosis must be made in order to correctly and appropriately guide management. This may include a combination of surgical debulking with or without intraperitoneal or systemic chemotherapy. We present a 52-year-old woman with a 4-month history of abdominal pain and distension with a previous appendicectomy 19 years earlier. Radiological and pathological investigations diagnosed a probable PMP secondary to ruptured appendicitis many years ago. We describe her unique case, with emphasis on length of time to diagnosis and clinical managemen...

Research paper thumbnail of Unicuspid aortic valve presenting with cardiac arrest in an adolescent

BMJ Case Reports, 2015

Unicuspid aortic valve (UAV) is a rare congenital anomaly typically affecting patients in their f... more Unicuspid aortic valve (UAV) is a rare congenital anomaly typically affecting patients in their fourth and fifth decades and presenting with signs of heart failure. Our case is one of a previously asymptomatic teenage girl with a UAV, who presented with cardiac arrest and was successfully treated. Only two other similar cases have been reported in the literature, both were of slightly older male patients. Our case highlights the morbidity associated with the anomaly supporting the need for careful assessment of the valve in cases where UAV is suspected.

Research paper thumbnail of Risk Factors for the Development of an Incisional Hernia After Sigmoid Resection for Diverticulitis: An Analysis of 33 Patient, Operative and Disease-associated Factors

The American surgeon, 2015

Incisional hernia (IH) is a relatively common sequelae of sigmoidectomy for diverticulitis. The a... more Incisional hernia (IH) is a relatively common sequelae of sigmoidectomy for diverticulitis. The aim of this study was to investigate factors that may predict IH in diverticulitis patients. Two hundred and one diverticulitis patients undergoing sigmoidectomy between January 2002 and December 2012 were identified (mean follow-up 5.15 ± 2.33 years). Patients with wound infections were excluded. Thirteen patient-associated, three diverticular disease-related, and 17 operative variables were evaluated in patients with and without IH. Volumetric fat was measured on preoperative CTs. Fischer's exact, χ(2), and Mann-Whitney tests and multivariate regression analysis were used for statistics. Thirty-four (17%) patients had an IH. On multivariate analysis, wound packing (OR 3.4, P = 0.017), postoperative nonwound infection (OR 7.4, P = 0.014), and previous hernia (OR 3.6, P = 0.005) were as independent predictors of IH. Fifteen of 34 (44%) patients who developed a hernia had a history of ...

Research paper thumbnail of Surgical diverticulitis is not associated with defects in the expression of wound healing genes

International journal of colorectal disease, Jan 24, 2015

The development of diverticuli may represent defects in collagen vascular tissue integrity possib... more The development of diverticuli may represent defects in collagen vascular tissue integrity possibly from a genetic predisposition. We evaluated the tissue expression of wound healing genes in sigmoid tissue from youthful patients undergoing surgery for diverticulitis and thus would more likely suffer from a genetic predisposition (SD mean age 39 ± 0.9) versus controls in the form of patients over the age of 50 (mean age 52.9 ± 10.5 years) without evidence of diverticular disease. The mRNA expression of 84 genes associated with the extracellular matrix, cellular adhesion, growth factors, inflammatory cytokines, and signal transduction was evaluated in 16 SD and 15 control tissues using a Qiagen(™) Wound Healing Array. Vitronectin, the gene protein with the highest potential significance on raw analysis, was further investigated using a Taqman assay with an additional 11 SD (total n = 27) and four control (total n = 19) samples. Statistics were by Student's t and Mann-Whitney test...

Research paper thumbnail of Measurement of visceral fat on preoperative computed tomography predicts complications after sigmoid colectomy for diverticular disease

American journal of surgery, Jan 7, 2015

Visceral and subcutaneous abdominal fat parameters have been associated with worse surgical outco... more Visceral and subcutaneous abdominal fat parameters have been associated with worse surgical outcomes in colorectal cancer but have not been investigated in diverticulitis. Volumetric fat parameters were measured on preoperative computed tomography scans from 211 diverticulitis patients. Primary outcome was a serious postoperative complication (Clavien-Dindo grades 2-4). Variables including age, disease duration, American Society of Anesthesiology score, ostomy, immunosuppression, body mass index, and volumetric fat parameters were examined. SPSS was used for statistics. The serious postoperative complication rate was 12.7%. On univariate analysis, several factors including older age (P = .0001), ostomy creation (P = .02), higher visceral fat (VF, P = .01), emergent surgery (P = .05), and higher American Society of Anesthesiology score (P = .05) were associated with complications. On multivariate regression analysis, only VF was independently associated with complications. Diverticul...

Research paper thumbnail of Outcome of open massive rotator cuff repairs with double-row suture knotless anchors: case series

International orthopaedics, Jan 12, 2015

The aim of the present study was to evaluate functional and quality of life outcomes after transo... more The aim of the present study was to evaluate functional and quality of life outcomes after transosseous equivalent (TOE) double row suture technique for massive rotator cuff (RTC) tear repair using validated subjective and objective measures. This technique has shown promising preliminary results in RTC repair; however, a paucity of evidence regarding these outcomes in massive RTC (MRTC) tear repair exists. Patients were identified using the Hospital Inpatient Enquiry Scheme. Pre-operative MRI and medical records were reviewed. A massive RTC tear was defined as the detachment of two or more tendons from their point of insertion on the humeral head. The Constant and Oxford Shoulder Scores (OSS) and SF-12 questionnaire were used for evaluation. Twenty-two patients were studied (72.7 % male; mean age at surgery, 62.6 years). Mean follow up was 14 (range six to 30) months. At six weeks postoperatively, 68 % achieved good or excellent shoulder function as measured by the OSS and Constant...

Research paper thumbnail of Predictors of recurrence of Crohn's disease after ileocolectomy: a review

World journal of gastroenterology : WJG, Jan 21, 2014

Recurrence after ileocolectomy for Crohn's disease (CD) is common and occurs in up to 80% of ... more Recurrence after ileocolectomy for Crohn's disease (CD) is common and occurs in up to 80% of patients. Such recurrence can result in repeated surgical interventions, an increased need for medical treatment and, frequently, an impaired quality of life. The aim of this overview is to provide a summary of the factors associated with disease recurrence after ileocolectomy for CD. Recurrence can be measured clinically or endoscopically using established scoring systems. Radiology and serologic tests can also be used, oftentimes in conjunction with endoscopy and/or clinical findings. Many patient and operative factors as well as pharmacologic treatments have been studied as potential predictors of recurrence. Of these, only smoking and immunomodulatory or biologic medical treatment have repeatedly been shown to effect recurrence. Genetic predictors have been studied and suggested but further evaluation in larger cohorts is necessary. This paper highlights validated, reproducible scori...

Research paper thumbnail of The surgical treatment of inflammatory bowel disease-associated dysplasia

Expert review of gastroenterology & hepatology, 2013

Surgical management of colonic dysplasia discovered in the inflammatory bowel disease patient is ... more Surgical management of colonic dysplasia discovered in the inflammatory bowel disease patient is controversial. Total proctocolectomy (TPC) is the most definitive treatment for the eradication of undiagnosed synchronous dysplasias and/or carcinomas and the prevention of subsequent metachronous lesions in both Crohn's disease (CD) and ulcerative colitis (UC). However, TPC is not always an attractive option owing to patient comorbidities and patient preference. Historically, dysplasia has been most studied in patients with UC, where the option of reconstruction without a stoma makes TPC more acceptable. Due to a relative lack of research on CD-related dysplasia, surveillance and treatment of CD dysplasia has followed paradigms based on UC data. However, due to pathophysiological differences in CD versus UC, options for surgical management in CD may be more varied than simple TPC, particularly in the less healthy surgical candidate and those who refuse end ileostomy.

Research paper thumbnail of TNFSF15 mRNA Expression Is Upregulated in Sigmoid Tissue of Diverticulitis Patients

Journal of the American College of Surgeons, 2014

Research paper thumbnail of Genetic Determinants Associated With Early Age of Diagnosis of IBD

Diseases of the Colon & Rectum, 2015

Inflammatory bowel disease (IBD) is typically diagnosed at 20 to 40 years of age. However, very y... more Inflammatory bowel disease (IBD) is typically diagnosed at 20 to 40 years of age. However, very young versus elderly patients with IBD may have different mechanisms of disease that may affect prognosis and care. The purpose of this work was to identify single nucleotide polymorphisms associated with age of onset of Crohn's disease and ulcerative colitis. Patients were genotyped using a custom microarray chip containing 332 IBD-associated single nucleotide polymorphisms. Age at diagnosis as a continuous variable was assessed using linear regression. Patients were then subgrouped by age at diagnosis and compared by the Fisher exact test. Bonferroni correction was used in all of the analyses. This study was conducted at a tertiary academic hospital. Sixty patients with Crohn's disease and 26 with ulcerative colitis were ≤ 16 years old, 259 patients with Crohn's disease and 248 with ulcerative colitis were 17-60 years old, and 10 patients with Crohn's disease and 20 with ulcerative colitis were >60 years old at diagnosis and included in this study. Age at diagnosis and single nucleotide polymorphism correlations were measured in this study. The NOD2 single nucleotide polymorphism rs2076756 was associated with younger age at Crohn's disease diagnosis (p = 0.0002). Patients with the AA/wild-type genotype were diagnosed at 31.9 ± 1.23 years, AG heterozygotes at 25.6 ± 0.99 years, and GG/at-risk allele homozygotes at 22.6 ± 1.32 years. Depending on age categories compared, single nucleotide polymorphisms in POU5F1, TNFSF15, and HLA DRB1*501 were associated with age of Crohn's disease diagnosis. No genetic associations were seen between ulcerative colitis and linear age at diagnosis; however, the G allele of the LAMB1 single nucleotide polymorphism rs886774 was found to be associated with ulcerative colitis diagnosed at ≤ 16 versus >17 years old (p = 0.008). This study was limited to known IBD single nucleotide polymorphisms. This analysis reaffirms the association between NOD2, a molecule of innate immunity, and early Crohn's disease onset. This is the first report of a possible association between early Crohn's disease and the POU5F1, TNFSF15, and HLA DRB1*501 genes. The LAMB1 gene, associated with mucosal basement membrane integrity, was associated with early onset ulcerative colitis and, thus, suggests a fundamentally different mechanism of early disease pathogenesis in ulcerative colitis versus Crohn's disease.

Research paper thumbnail of Organ space infection after ileocolectomy for Crohn's disease: a National Surgical Quality Improvement Project study

Organ space infection (OSI) rates post ileocolectomy for Crohn&am... more Organ space infection (OSI) rates post ileocolectomy for Crohn's disease are relatively high. The aim of this study was to determine which factors predispose to OSI in this patient cohort. Data for 2,618 Crohn's patients undergoing ileocolectomy between 2005 and 2011 were obtained from the American College of Surgeons National Surgical Quality Improvement Project database. Primary outcome was an OSI within 30 days of discharge. Univariate analysis using chi-square and Student t tests and a logistic multivariate analysis were performed. Preoperative weight loss (odds ratio [OR] 2.11, P = .002), extended operating time (OR 1.57, P = .016), open procedures (OR 1.47, P = .043), and contaminated/dirty wounds (OR 1.95, P = .008) conferred an increased risk for OSI on multivariate analysis. Rates of stoma creation and steroid use were not significantly different between the groups. Weight loss is a preoperative, potentially modifiable variable associated with OSI in Crohn's patients undergoing ileocolectomy and OSI-associated operative factors which may be noted to identify high-risk patients include extended operating time and open procedures.

Research paper thumbnail of An interleukin-4 polymorphism is associated with susceptibility to Clostridium difficile infection in patients with inflammatory bowel disease: Results of a retrospective cohort study

Surgery, 2014

Background. Clinical studies have suggested that patients with inflammatory bowel disease (IBD) a... more Background. Clinical studies have suggested that patients with inflammatory bowel disease (IBD) are at greater risk for developing Clostridium difficile infection (CDI). The purpose of this study was to identify single-nucleotide polymorphisms (SNPs) associated with CDI among IBD patients.

Research paper thumbnail of Ulcerative colitis neoplasia is not associated with common inflammatory bowel disease single-nucleotide polymorphisms

Surgery, 2014

Background. Neoplasia complicating ulcerative colitis (UC-neoplasia) is a problem that is poorly ... more Background. Neoplasia complicating ulcerative colitis (UC-neoplasia) is a problem that is poorly addressed by present surveillance techniques. The association of greater than 300 single nucleotide polymorphisms (SNPs) with inflammatory bowel disease (IBD) suggests the possibility that certain genetic polymorphisms might identify patients with UC destined for malignant degeneration. This present study tested the hypothesis that presently known IBD-associated SNPs may correlate with UC-neoplasia. Materials and methods. A total of 41 patients with UC-neoplasia (mean age 56 ± 2.1 years) were identified from our divisional IBD Biobank (low-grade dysplasia n = 13, high-grade dysplasia n = 8, colorectal cancer [CRC] n = 20). These patients were individually age, sex, and disease duration matched with UC patients without neoplasia. Primary sclerosing cholangitis and family history of CRC were recorded. Patients were genotyped for 314 of the most commonly IBD-associated SNPs by a custom SNP microarray. Logistic regression and Fischer exact test were used for statistical analysis. Results. After Bonferroni correction, none of the 314 IBD-associated SNPs correlated with UC-neoplasia when compared with matched UC controls. The incidence of primary sclerosing cholangitis was greater in the UC-neoplasia group (10/41, 24% vs 3/41, 7%; P = .03) compared with UC controls. The severity of neoplasia (low grade dysplasia versus high grade dysplasia versus CRC) correlated with disease duration (7.9 vs 13.4 vs 20.7 years, respectively). Conclusion. The lack of correlation between well-known IBD-associated SNPs and UC-neoplasia demonstrated in this study suggests that the development of neoplasia in patients with UC is associated with genetic determinants other than those that predispose to inflammation or results from posttranslational modifications or epigenetic factors rather than germline polymorphisms. (Surgery 2014;156:253-62.)

Research paper thumbnail of Increased Risk of Incisional Hernia after Sigmoid Colectomy for Diverticulitis Compared with Colon Cancer

Journal of the American College of Surgeons, 2014

We aimed to determine if an increased incidence of incisional hernias is present in patients unde... more We aimed to determine if an increased incidence of incisional hernias is present in patients undergoing sigmoidectomy for diverticulitis vs cancer. The pathophysiology of diverticulitis is poorly understood, but might involve a collagen vascular abnormality that can predispose to incisional hernia. In this IRB-approved, retrospective study, patients who underwent sigmoid colectomies for diverticulitis or cancer between January 2003 and September 2012 were studied. Exclusion criteria included the development of surgical site infections and neoadjuvant chemoradiotherapy. A multivariate logistic regression was used with covariate adjustments for known risk factors for hernia development. Four hundred forty-two patients (mean age 59.3 ± 13.9 years) with a median follow-up of 30 months were analyzed. The incidence of incisional hernia was 15.1% in diverticulitis patients vs 5.8% in the cancer cohort (41 of 271 vs 10 of 171; p = 0.003). Univariate analysis of risk factors associated with postoperative incisional hernia included steroid use (p = 0.007), wound packing (p = 0.001), higher American Society of Anesthesiologists classification (p = 0.001), absorbable suture closure (p = 0.02), blood transfusion (p = 0.04), stoma formation (p = 0.02), increased body mass index (p = 0.008), and history of incisional hernia (p = 0.00008). Multivariate logistic regression demonstrated a persistent association between diverticulitis and hernia development (p = 0.01). Odds of a hernia developing after sigmoidectomy for diverticulitis were 2.82 times greater than in the cancer cohort (95% CI, 1.3-6.6). The incidence of an incisional hernia developing after a sigmoid colectomy is significantly higher when performed for diverticulitis as compared with cancer. This might be due to a connective tissue disorder, which predisposes to development of both diverticula and hernias.