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Examining the relationship between lymph node harvest and survival in patients undergoing colectomy for colon adenocarcinoma

Trepanier, Maude; Erkan, Arman; Kouyoumdjian, Araz; Nassif, George; Albert, Matthew; Monson, John; Lee, Lawrence
BACKGROUND:Current standards for lymph node harvest in colorectal cancer surgery may be inadequate. Higher lymph node yield may improve survival, but the number of lymph nodes needed to optimize survival is unknown. The objective of this study was to examine the relationship between lymph node yield and overall survival in patients undergoing colectomy for nonmetastatic colon adenocarcinoma. METHODS:The 2010 to 2014 National Cancer Database was queried for patients undergoing colectomy for nonmetastatic colon adenocarcinoma. Adjusted restricted cubic splines were used to model the nonlinear relationship between lymph node harvest and overall survival. Cox proportional hazard determined independent predictors of overall survival. RESULTS:A total of 261,423 patients were included. Restricted cubic splines demonstrated that the adjusted improvements in overall survival stabilized after 24 nodes. Patients were divided into: <12, 12 to 23, and ≥24 nodes. On survival analysis, patients with ≥24 nodes had better survival across all N stages compared to other groups (P < .001). Lymph node harvest ≥24 nodes was independently associated with improved overall survival compared to 12 to 23 nodes (hazard ratio 0.82; 95% confidence interval, 0.80-0.85). CONCLUSION/CONCLUSIONS:Lymph node harvest ≥24 nodes is associated with improved survival in colorectal cancer patients. These data may provide indirect evidence for a more extensive lymphadenectomy for colon cancer.
PMID: 31399220
ISSN: 1532-7361
CID: 4141582

Impact of residual nodal involvement after complete tumor response in patients undergoing neoadjuvant (chemo)radiotherapy for rectal cancer

Erkan, Arman; Mendez, Alvaro; Trepanier, Maude; Kelly, Justin; Nassif, George; Albert, Matthew R; Lee, Lawrence; Monson, John R T
BACKGROUND:The management of patients with a complete clinical response after neoadjuvant therapy for rectal adenocarcinoma is controversial. Those who advocate for resection point out the inaccuracy of N-staging with current imaging modalities. The objective of this study is to determine the impact of residual nodal involvement after complete tumor regression after neoadjuvant (chemo)radiotherapy. METHODS:The 2004 to 2014 National Cancer Database was queried for patients undergoing proctectomy for nonmetastatic rectal adenocarcinoma who had received neoadjuvant (chemo)radiotherapy and with ypT0 on final pathology. Patients were grouped based on pathologic nodal stage: ypT0N- and ypT0N+. The main outcome was 5-year overall survival. RESULTS:There were 5,156 patients with ypT0N- and 527 with ypT0N+. Mean lymph node harvest was similar (ypT0N- 12.2 nodes [standard deviation 9.1] vs ypT0N+ 11.6 nodes [standard deviation 10.3]; P = .086). Patients with ypT0N+ were more likely to have had clinically involved nodes (P < .001) and earlier clinical T-stage (P = .002). Overall survival at 5 years was less for patients with ypT0N+ (80% vs 86%, log-rank P = .014). ypT0N+ was independently associated with worse overall survival (hazard ratio 1.74, 95% confidence interval 1.33-2.28). CONCLUSION/CONCLUSIONS:Residual nodal involvement despite complete tumor regression was associated with worse 5-year overall survival compared to complete pathologic response. Additional therapy should be considered in the presence of complete clinical tumor regression after neoadjuvant (chemo)radiotherapy.
PMID: 31378480
ISSN: 1532-7361
CID: 4141572

Lower survival after right-sided versus left-sided colon cancers: Is an extended lymphadenectomy the answer?

Lee, Lawrence; Erkan, Arman; Alhassan, Noura; Kelly, Justin J; Nassif, George J; Albert, Matthew R; Rt Monson, John
INTRODUCTION/BACKGROUND:Tumour location may affect oncologic outcomes for colon adenocarcinoma due to different levels of vascular ligation and nodal harvest, but the data are equivocal. The objective of this study is to determine the effect of tumor location and lymph node yield on overall survival(OS) in stage I-III colon adenocarcinoma. METHODS:The 2004-2014 National Cancer Database was queried for colectomies for non-metastatic colon adenocarcinoma, excluding transverse colon and rectal cancer. Patients were grouped based on left/right tumor location. Main outcome measure was 5-year OS. Propensity score matching created balanced cohorts. Multilevel survival analysis determined the independent effect of tumor location and nodal harvest on OS. RESULTS:There were 504,958 patients (273,198 right; 231,760 left) in the entire cohort: 26.4% stage-I, 37.3% stage-II, and 36.3% stage-III (equal distribution left/right). After 1:1 matching(n = 297,080), right cancers were associated with worse 5-year overall survival for stage-II (66% vs. 70%, p < 0.001) and -III (56% vs. 60%, p < 0.001) despite similar nodal harvest and proportion receiving systemic therapy. On multivariate analysis, right-sided cancers (HR 1.12, 95%CI 1.06-1.19) had worse OS, independent of stage and nodal harvest. Nodal harvest ≥22 nodes had the highest OS (HR 0.71, 95%CI 0.68-0.75). There was an interaction between right-sided cancer and >22 lymph node harvest towards increased survival (HR 0.86, 95%CI 0.80-0.92). CONCLUSIONS:Right-sided cancers are associated with worse oncologic outcomes compared to left-sided tumors but a higher lymph node yield improves survival. These data provide indirect evidence for a higher lymphatic harvest to improve survival.
PMID: 30217301
ISSN: 1879-3320
CID: 4141562

Scope or scalpel? A matched study of the treatment of large colorectal polyps

Church, James; Erkan, Arman
BACKGROUND:Large colorectal polyps can be treated either endoscopically or by formal resection. The aim of this study was to clarify the relative advantages and disadvantages of surgical resection and colonoscopic snaring as means of treating large colorectal polyps. METHODS:This is a matched cohort study, comparing cases of surgical resection of benign colorectal polyps with endoscopic resection. Cases drawn from pathology and endoscopy databases were matched for the size and site of polyps, and the groups were compared for the end points of complications, length of hospital stay and completeness of the removal of the polyp. RESULTS:There were 78 patients in each group, with mean ages of 65.6 years (colonoscopy) and 66.8 years (surgery). A total of 39 of the surgery group and 47 of the colonoscopy group were men. Mean polyp size was 34.1 mm (colonoscopy) and 32.1 mm (surgery). There was an exact match for polyp location. Complications occurred in eight colonoscopy patients (10.3%) and 42 surgery patients (56.0%) (P < 0.001, chi-square). Length of hospital stay was 0 days for colonoscopy patients and 7.3 ± 4.7 days for surgery (P < 0.001). The surgery group was separated into laparoscopic (n = 35) and open (n = 43) surgery. There was no difference in complication rates (42.4 versus 53.5%, respectively) but laparoscopic had shorter length of stay (5.8 days ± 4.9 SD versus 8.4 days ± 4.3 SD). Recurrence of surgically resected polyps was zero; at last follow-up 13% of snared polyps persisted. CONCLUSION/CONCLUSIONS:Although resection is a more certain and absolute way of treating benign polyps, endoscopic polypectomy is preferable.
PMID: 27491016
ISSN: 1445-2197
CID: 4141552

Mesothelial Cysts of the Round Ligament of the Uterus in 9 Patients: a 15-year experience

Tirnaksiz, Mehmet; Erkan, Arman; Dogrul, Ahmet Bulent; Abbasoglu, Osman
Aim of this study was to evaluate the characteristic features of patients with mesothelial cyst of the round ligament of the uterus and the incidence of this entity. This was a retrospective review of 3065 patients who underwent inguinal exploration for groin mass from 1998 to 2013. Clinical, radiological and histopathological features of patients with a diagnosis of mesothelial cyst of the round ligament were analyzed. Of the 405 female patients reviewed 9 mesothelial cysts of the round ligament were identified (2.2%). The median age was 37 (range 19-82 years). In all patients the groin mass was manually irreducible on physical examination. The lesions were on the right side in 6 (66.6%) patients. These were identified before surgery in 4 (all by groin ultrasonography). Three were misidentified as a hernia before surgery. The remaining 2 (22%) had both hernia and the mesothelial cyst of the round ligament. The cysts were identified after surgery at the time of histopathological examination in these two patients. In all patients histopathological examination revealed multilobular cystic lesion lined by a single layer of mesothelial cells. Cystic lesions arising from the round ligament were identified and excised along with the round ligament in 7 patients. In the remaining 2, a hernia repair was also performed. There was no recurrence at follow-up. Mesothelial cysts of the round ligament are rare. They are easily misidentified as groin hernia. An accurate diagnosis requires a high index of suspicion and is greatly aided by preoperative imaging studies.
PMID: 27042871
ISSN: 2520-2456
CID: 4141542

Double Incomplete Internal Biliary Fistula: Coexisting Cholecystogastric and Cholecystoduodenal Fistula

Beksac, Kemal; Erkan, Arman; Kaynaroglu, Volkan
Internal biliary fistula is a rare complication of a common surgical disease, cholelithiasis. It is seen in 0.74% of all biliary tract surgeries and is thought to be a result of repeated inflammatory periods of the gallbladder. In this report we present a case of incomplete cholecystogastric and cholecystoduodenal fistulae in a single patient missed by ultrasonography and endoscopic retrograde cholangiopancreatography and diagnosed intraoperatively. In the literature there is only one report of an incomplete cholecystogastric fistula. To our knowledge this is the first case of double incomplete internal biliary fistulae.
PMCID:4745309
PMID: 26904348
ISSN: 2090-6900
CID: 4141532