Ochsner Clinic Research Articles

Sa1525 Prophylactic Pancreatic Duct Stenting for Prevention of Post-ERCP Pancreatitis: an Updated Meta-Analysis

Prophylactic Pancreatic Duct Stenting for Prevention of PostERCP Pancreatitis: an Updated Meta-Analysis Anupama Inaganti*, Naga Swetha Samji, Rajan Kanth, Sarah D. Komanapalli, Mainor R. Antillon, Ramon E. Rivera, Praveen K. Roy Internal Medicine, Marshfield Clinic, Marshfield, WI; Gastroenterology and Hepatology, Ochsner Clinic, New Orleans, LA Background: Post ERCP acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The efficacy of prophylactic pancreatic duct stent for prevention of post-ERCP pancreatitis (PEP) has been studied in several randomized controlled trials (RCTs). We conducted an updated meta-analysis to evaluate the efficacy and safety of prophylactic pancreatic duct stenting for the prevention of PEP. Methods: Pubmed, Embase, CINHAL, the Cochrane Library and abstracts from major conference proceedings were searched for relevant articles. RCTs assessing the efficacy of prophylactic pancreatic duct stenting with no stent in preventing post ERCP pancreatitis were included in the analysis. Data was extracted by two independent reviewers using standard forms. Data on patient demographics, indications, complications and characteristics of stents used was extracted for analysis. Pooled estimates of PEP, hyperamylasemia, and grade of pancreatitis were analyzed to evaluate the effect of stents. Separate analyses were performed for each outcome by using the risk ratio (RR) or weighted mean difference. Publication bias was assessed using funnel plots. Random effects models were used. Results: Thirteen RCTs met the inclusion criteria (1438 subjects). 6 studies were performed in the United States, 5 studies in Japan, 1 in South Korea and 1in China. 551 females were included from 8 studies. Mean age was 18-92 years. 12 studies included high risk group patients. 5 Fr stents were used in 11 studies, 3 Fr and 7 Fr stent in one study each. Unflanged stents were used in 5 studies. Shorter stents 3 cm were used in eight studies. Stent placement was successful in 88.3% to 100% of patients (3 studies). 6 of the studies used protease inhibitors. Meta-analysis of RCTs showed that prophylactic pancreatic stents reduced the risk of developing post ERCP pancreatitis RR 0.37 (95% CI 0.26-0.52, p 0.0001). The number needed to treat was 8. There was significant risk reduction in severe PEP RR 0.26 (95% CI 0.080.83, p 0.02) with pancreatic stents. Reduction in mild pancreatitis RR 0.502 (95% CI 0.341-0.502, p-value 0.001) and moderate pancreatitis RR 0.346 (95% CI 0.169-0.709, p 0.004) was also noted. No significant decrease in hyperamylasemia was noted (weighted mean difference -294.488, 95% CI 11.3600.3, p 0.06). Stents were left in place for 3-7 days and spontaneous dislodgement rate was 90% to 96.7%. Mean duration of dislodgement was 2-3.5 days (5 studies). Conclusion: Pancreatic stents decrease the risk of post ERCP pancreatic pancreatitis in high risk groups. In addition, the risk of severe pancreatitis was lower with pancreatic stents.

Initial experience using the Penumbra coil 400: comparison of aneurysm packing, cost effectiveness, and coil efficiency

Background/objectiveThis was a retrospective single operator experience of aneurysm coiling at the Ochsner Clinic, comparing the Penumbra coil 400 with the other most commonly used coil types, Orbit and Galaxy.Methods40...

Explaining the Recent Fish Oil Trial “Failures”

1Department of Medicine, Wegmans Pharmacy, Ithaca, New York, USA 2Department of Medicine, Shifa College of Medicine, Islamabad, Pakistan 3Department of Medicine, Mid American Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA 4Department of Medicine, John Ochsner Heart and Vascular Institute, Ochsner Clinical SchoolThe University of Queensland School of Medicine, New Orleans, LA and Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA

Editorial introductions

Editorial introductions

E-021 Initial experience using the Penumbra Coil 400: comparison of aneurysm packing and coil efficiency

IntroductionPenumbra Coil 400 gained FDA approval and was introduced to the market April 2011. Due to its larger 0.020″ diameter and inherent softness, there is potential to provide more efficient...

Jaime L. Bohl, M.D.

Dr. Jaime L. Bohl is an Assistant Professor of Surgery, Department of Surgery, Wake Forest School of Medicine and a Colon and Rectal Surgeon at Wake Forest Baptist Health in Winston-Salem, North Carolina. Jaime was born in Rockville, Connecticut. She grew up in the suburbs of Boston, Massachusetts. Dr. Bohl graduated from Duke University in Durham, North Carolina and attended medical school at the University of Virginia in Charlottesville, Virginia. She completed her general surgery residency at Vanderbilt University in Nashville, Tennessee and her colorectal surgery training at the Lahey Clinic in Burlington, Massachusetts. After this, she joined the Ochsner Clinic Foundation as a Staff Colon and Rectal Surgeon in the Department of Colon and Rectal Surgery in New Orleans, Louisiana. In 2011, she was recruited to her present position. Dr. Bohl is a rising star in the area of hereditary colorectal cancer. She conducts research in this area and actively participates in forums and committees on a national level to improve our knowledge and management of these challenging patients. In addition to managing many patients with hereditary colorectal cancer, Dr. Bohl maintains a busy clinical colorectal surgery practice in a university setting; she also teaches and interacts with medical students and residents daily. In addition to her research efforts, Dr. Bohl has published four book chapters and over four peer-reviewed articles. These include several contributions to Clinics. Dr. Bohl is a fellow of the American College of Surgeons. She serves on several committees and is a member of multiple specialty societies. She is Board Certified in General Surgery and Colon and Rectal Surgery and is also listed in Best Doctors in America. Jaime lives in Winston-Salem with her husband Nick. When not working, she enjoys running and participating in international medical missions. On behalf of the readers of Clinics in Colon and Rectal Surgery, the Editorial Board thanks Dr. Bohl for serving as Guest Editor and for providing an important issue on hereditary colon and rectal cancer.

Introduction to Guest Editor

Dr. David E. Beck is Chairman of the Department of Colon and Rectal Surgery at the Ochsner Clinic, New Orleans, Louisiana. Dave was born in Geneva, Illinois. He received a BS degree as a distinguished graduate from the United States Air Force Academy and his MD from the University of Miami in Florida. He completed his general surgery residency at Wilford Hall USAF Medical Center at Lackland AFB, Texas. After spending a year as an Air Force general surgeon at a small base in Florida, he completed a fellowship in Colon and Rectal Surgery at the Cleveland Clinic. Dr. Beck then returned to Wilford Hall to serve as the Chief of Colon and Rectal Surgery and eventually as Chairman of the Department of General Surgery. During his Air Force career, he served as the Air Force Surgeon General's Consultant in Colon and Rectal Surgery and during the Gulf War served as Chief of Surgery at the 81 Contingency Hospital located at Little Rissington, United Kingdom. In 1993, he joined the colorectal staff at the Ochsner Clinic and in 1995 became Chairman of the Department of Colon and Rectal Surgery. In 2005, he was elected to the Board of Governors of the Ochsner Clinic. Dr. Beck maintains a busy clinic practice in New Orleans with an emphasis on inflammatory bowel disease, anal cancer, stomas, adhesions, bowel preparation, sphincter-saving surgery for cancer, and laparoscopic surgery. He also sees many patients with functional bowel disease. Dr. Beck educates medical students, residents, and colorectal surgery trainees on a daily basis and mentors trainees and junior faculty. He is a Professor of Surgery at the University of Queensland, Australia and is on the clinical faculty at the Louisiana State University and the Uniformed Services University Schools of Medicine. Dr. Beck assumed the duties of Editor in Chief of Clinics in Colon and Rectal Surgery in January 2000. He has previously served on the Editorial Board of Diseases of the Colon and Rectum and is also currently the Editor in Chief of The Ochsner Journal. Dr. Beck has been a guest editor of several previous issues of Clinics and is the author and editor of seven textbooks, including the first and second editions of the American Society of Colon and Rectal Surgery (ASCRS) Textbook of Colon and Rectal Surgery and the ASCRS Manual of Colon and Rectal Surgery, as well as the third edition of the Handbook of Colon and Rectal Surgery. He has published more than 100 book chapters and monographs and more than 150 peer-reviewed articles. Dr. Beck is the immediate past president of the ASCRS and serves on multiple committees of the ASCRS, and is a member of multiple medical associations. An active researcher, Dr. Beck received the ASCRS Outstanding Young Investigator's Award in 1992, and is a member of the board of trustees of the ASCRS Research Foundation. He is also listed in Best Doctors in America, Who's Who in America, and was selected as one of Good Housekeeping's Top 318 Cancer Doctors for Women. David Beck and his wife, Sharon, live in Madisonville, Louisiana. When not working, he enjoys fishing, gardening, and woodworking. On behalf of the readers of Clinics in Colon and Rectal Surgery, the editorial board thanks Dr. Beck for serving as Guest Editor and for providing an important issue on functional bowel disease.

Physical Fitness-An Often Forgotten Cardiovascular Risk Factor

1Department of Preventive Medicine, Pennington Biomedical Research Center, Baton Rouge, LA, USA 2Department of Cardiovascular Diseases, John Ochsner Heart & Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA, USA 3Physical Therapy Program-Department of Orthopaedics and Rehabilitation and Division of Cardiology-Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA

H. David Vargas, M.D.

Dr. H. David Vargas is an Associate Professor of Surgery and Chief of the Section of Colon and Rectal Surgery at the University of Kentucky in Lexington, Kentucky. Dave was born in Hamilton-Ontario, Canada and received his M.D. from the University of Virginia School of Medicine. He completed an internship in Family Practice at Shadyside Hospital in Pittsburgh, Pennsylvania and experienced an epiphany, switching to general surgery training at Lehigh Valley Hospital in Allentown, Pennsylvania. He then completed a fellowship in Colon and Rectal Surgery at the Ochsner Clinic in New Orleans, Louisiana. After his fellowship, he went into practice for 2 years in Allentown, Pennsylvania then moved to a multi-specialty group in Norfolk, Virginia. In 2004, he joined his cousin Ray Ramirez in a new colorectal surgery group in Hampton, Virginia. After 3 years, he was recruited to his current position at the University of Kentucky. Certified in General and Colon and Rectal Surgery, David teaches general surgery residents and students on a daily basis. He has excelled in his return to academic practice, as evidenced by several teaching awards bestowed upon him including the Chief Resident's Award recognizing excellence in the instruction of operative technique and surgical judgment, and the Ward O. Griffin Award for excellence in the teaching of medical students. His contributions to the medical literature include a book chapter and 10 peer-reviewed articles. David has a busy clinical practice, which unfortunately includes a significant number of obese patients. He is an active member of several surgical societies and is a fellow of the American College of Surgery and the ASCRS. He also serves on several major committees of the ASCRS. His experience in several varied practices gives him a unique perspective on many of the topics discussed in this issue of Clinics in Colon and Rectal Surgery. Dave, his wife Mercedes, and their children Gabriella, Luke, and Marco live in Lexington, Kentucky. When not working, Dave enjoys mountain biking, salt-water fishing, coaching his children in soccer, and trying to maintain a reasonable body weight while enjoying his wife's spectacular cooking. On behalf of the readers and staff of Clinics in Colon and Rectal Surgery, my thanks to Dr. Vargas for serving as Guest Editor and providing us with an excellent issue on colon and rectal surgery in the obese patient.

Choosing Your Goals

Department of Colon and Rectal Surgery, Ochsner Clinic, New Orleans, Louisiana Financial Disclosures: None reported. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Vancouver, BC, Canada, May 15 to 18, 2011. Correspondence: David E. Beck, M.D., Department of Colon and Rectal Surgery, Ochsner Clinic, 1514 Jefferson Highway, New Orleans, LA 70121. E-mail: [email protected]

Editorial introductions

Current Opinion in Nephrology and Hypertension was launched in 1992. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of nephrology and hypertension is divided into 12 sections that are each reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. Section Editors George BakrisGeorge BakrisDr Bakris received his medical degree from the Chicago Medical School, USA and completed residency in Internal Medicine at the Mayo Graduate School of Medicine, where he also did a research fellowship in Physiology and Biophysics. He then completed fellowships in Nephrology and Clinical Pharmacology at the University of Chicago. From 1988 to 1991, he served as Director of Renal Research at the Ochsner Clinic and was a faculty member of Tulane University School of Medicine. He was also Professor and Vice Chairman of Preventive Medicine and Director of the Rush University Hypertension Center in Chicago, IL (USA) from 1993 until 2006. Currently, he is Professor of Medicine and Director of the Hypertensive Diseases Unit in the Section of Endocrinology, Diabetes and Metabolism at the University of Chicago Pritzker School of Medicine. Dr Bakris has published over 500 articles and book chapters in the areas of kidney disease hypertension and progression of nephropathy. He is the Editor or Co-Editor of eight books, all dealing with kidney disease, diabetes and the role of hypertension. These include: The Kidney and Hypertension, Hypertension: a Clinician's Guide to Diagnosis and Treatment and Hypertension: Principles and Practice, Handbook of Hypertension, The Kidney in Cardiovascular Disease, Therapeutic Strategies in Hypertension, Microalbuminuria and Cardiovascular Risk and Lower Extremity Arterial Disease. Additionally, he is the Associate Editor of the International Textbook of Cardiology. He has also served as the co-principal investigator of an NIH Clinical Research training grant (K30) to train clinical researchers (1999–2004). Adam Whaley-ConnellAdam Whaley-ConnellDr Whaley-Connell received his medical degree from the Kansas City University of Medicine and Biosciences, USA. He then completed a residency in Internal Medicine at the University of Missouri-Columbia School of Medicine, USA where he also did a clinical and research fellowship in Nephrology. Since then he has been on faculty as an Assistant and now Associate Professor of Medicine and currently runs the Hypertension clinic at the Harry S Truman VA Medical Center. His research program is funded through the Dept of Veterans Affairs and the National Institute of Aging and focuses on the renin-angiotensin-aldosterone system. Dr Whaley-Connell has published over 150 peer-reviewed publications and book chapters in the areas of kidney disease and hypertension. He serves on more than 5 editorial boards and sits on two standing NIH study sections. Dr Whaley-Connell also serves as co-Chair of the National Kidney Foundation (NKF) Kidney Early Evaluation Program and Cardio Kidney Work group. Alan YuAlan YuAlan Yu received his medical degree from the University of Cambridge and trained in internal medicine and nephrology at the Brigham and Women's Hospital and Harvard Medical School, USA. He is currently the Harry Statland and Solon Summerfield Professor of Medicine at the University of Kansas, and Director of the Kidney Institute and the Division of Nephrology and Hypertension at the University of Kansas Medical Center. Dr Yu conducts basic science research on renal transport physiology and epithelial biology, with a focus on the role of tight junctions in the regulation of paracellular permeability. In addition to editing Current Opinion in Nephrology and Hypertension, Dr Yu serves on the editorial boards of the Journal of Biological Chemistry, American Journal of Physiology: Renal Physiology, Frontiers in Renal and Epithelial Physiology, and Faculty of 1000 Medicine, and edits the textbook “Brenner & Rector's The Kidney”. Dr Yu is currently a member of the American Society of Clinical Investigation, American Society of Nephrology, and the American Physiological Society.

Drug-eluting coronary stents – focus on improved patient outcomes

The development of stent has been a major advance in the treatment of obstructive coronary artery disease since the introduction of balloon angioplasty. Subsequently, neointimal hyperplasia within the stent leading to in-stent restenosis emerged as a major obstacle in long-term success of percutaneous coronary intervention. Recent introduction of drug-eluting stents is a major breakthrough to tackle this problem. This review article summarizes stent technology, reviews progress of drug-eluting stents and discusses quality of life, patient satisfaction, and acceptability of percutaneous coronary intervention.

Since Katrina: Neonatal and Pediatric Issues From Both Sides of the Levee

Geographic circumstances: I directed the NICU during Hurricane Katrina and the subsequent flood on the dry side of the levee. I continue to practice neonatology in the same hospital and continue to prepare for hurricanes. About the author: I joined the staff of the Ochsner Clinic in 1987 as a neonatologist, and I am currently the section head of neonatal medicine and medical director of the Ochsner Foundation Hospital's level III regional NICU. As a member of team A, it was my responsibility to run the NICU in the event of any disaster. I was in the Ochsner NICU in the days that led up to, during, and for the 9 days after Hurricane Katrina. With the departure of half of our neonatology staff over the ensuing 12 months, my partner and I were responsible for resurrecting our unit and providing care for up to 42 infants. Since that time, the staff now consists of 5 full-time neonatologists who provide care for neonates in 3 NICUs in the New Orleans area. Failure of the levee system in southeast Louisiana and flooding associated with Hurricane Katrina forever changed the landscape in innumerable ways. The delivery of health care services including obstetric and newborn care did not remain unscathed. Since Katrina in August, 2005, the levee system surrounding New Orleans has been enhanced with both improvements in drainage and pumping capacity. In places where pumping stations were actually forced to shut down because of the need to evacuate pump-station operations personnel, attached “safe houses” have been constructed. Major highway construction projects are underway, and some that are near completion will allow for improved evacuation of the population when necessary. Those people whose health requires them to be hospitalized during a local disaster will find themselves in a much improved environment than was … Address correspondence to Harley G. Ginsberg, MD, NICU, Ochsner Clinic Foundation, 1516 Jefferson Hwy, 10th Floor—NICU, Room 1040, New Orleans, LA 70121. E-mail: hginsberg{at}ochsner.org

Lysosomal action of intracrine angiotensin II. Focus on “Intracellular angiotensin II activates rat myometrium”

forty years ago, Robertson and Khairallah ([20][1]) demonstrated that tritiated angiotensin II (ANG II) rapidly localized in myocyte nuclei and mitochondria after intracardiac injection. This finding was confirmed and expanded upon over the subsequent decades with the result that the notion of

David E. Beck, M.D.

Dr. David E. Beck is Chairman of the Department of Colon and Rectal Surgery at the Ochsner Clinic, New Orleans, Louisiana. Dave was born in Geneva, Illinois. He received a BS degree as a distinguished graduate from the United States Air Force Academy and his MD from the University of Miami in Florida. He completed his general surgery residency at Wilford Hall USAF Medical Center at Lackland AFB, Texas. After spending a year as an Air Force general surgeon at a small base in Florida, he completed a fellowship in Colon and Rectal Surgery at the Cleveland Clinic. Dr. Beck then returned to Wilford Hall to serve as the Chief of Colon and Rectal Surgery and eventually as Chairman of the Department of General Surgery. He has also served at the Air Force Surgeon General's consultant in Colon and Rectal Surgery and during the Gulf War was Chief of Surgery at the 81 Contingency Hospital located at Little Rissington, United Kingdom. After leaving active military service in 1993, he joined the colorectal staff at the Ochsner Clinic and in 1995 became chairman of the department in 1997. In 2005, he was elected to the Board of Governors of the Ochsner Clinic.

A single-center experience of small-bowel adenocarcinomas.

337 Background: The age-adjusted incidence of small-bowel adenocarcinomas was reported as 1.9 per 100,000 per year (SEER 2003-2007). Even early-stage small bowel tumors are associated with a high risk of recurrence. We performed a retrospective chart review to analyze location, stage at presentation, and recurrence rate of early-stage small-bowel adenocarcinomas at our institution. Methods: Institutional (Ochsner Clinic) tumor registry database was used to identify patients with small-bowel adenocarcinoma from 1983 onward. Medical records were reviewed for pertinent patient information. Results: 44 patients (24 males, 20 females) were identified. 25 (56.8%) patients had a duodenal primary, 8 (18.1%) jejunal, 4 (9.0%) ileal, and 7 (15.9%) patients did not have a documented site of origin. Mean age at presentation was 64 yrs (range 31-84 yrs). The most common presenting symptoms were abdominal pain (40%), melena (25%), and small-bowel obstruction (16%). Histological grade II or III accounted for 64% of all tumors. Almost half of the patients (43.2%) presented with stage IV disease, which was associated with a median survival of 11.5 months. All patients staged as I, II, and III had a curative resection including 33% who underwent a Whipple's surgery. Four patients were not seen in follow-up at our institution and 6 patients died in the postoperative period from various complications. No stage I patient received adjuvant chemotherapy. All available stage II and III patients received adjuvant 5-FU based chemotherapy. The chemotherapy received was as follows: Stage II (two 5-FU, two FOLFOX); Stage III (four 5-FU, one capecitabine/irinotecan, one FOLFOX). The recurrence for each stage is shown in the Table. Conclusions: Although our numbers are small, stage I adenocarcinomas of the small bowel had a significant risk of recurrence. This warrants a multi institutional review of patient data to better quantify the risk of recurrence for this rare tumor and the implications for treatment trials. [Table: see text] No significant financial relationships to disclose.

Prevalence of clinical venous thromboembolism in the USA: Current trends and future projections

The U.S.-wide prevalence of venous thromboembolism (VTE) is unclear, with reported VTE incidence estimates varying widely. This retrospective analysis of healthcare claims data from patients in the Thomson Reuters national MarketScan(®) Commercial and Medicare databases (January 2002-December 2006) estimates the U.S. prevalence of VTE, and assesses associated temporal trends. Of 12.7 million study-eligible patients, 200,007 had VTE. The overall prevalence of VTE (cases per 100,000) increased by 33.1% during the study period: from 317 in 2002 to 422 in 2006. VTE was more prevalent in women than men throughout the study. The annual prevalence of VTE increased with age: 1,382 in patients ≥65 years versus 231 in patients <65 (2006 data). The number of U.S. adults with VTE is projected to more than double from 0.95 million in 2006 to 1.82 million in 2050. These data confirm that VTE remains a major healthcare burden in the US, particularly among the elderly, and highlight a continuing increase in prevalence of the disease. Greater efforts are required to improve awareness of VTE and improve standards of VTE prevention in healthcare organizations.

Extracorporeal Gastric Stapling Reduces the Incidence of Gastric Conduit Failure after Minimally Invasive Esophagectomy

Esophageal cancer resection is associated with significant morbidity and mortality. To date, no standardized technique exists. In this study, we analyze our short-term results in 92 minimally invasive resections performed over the past 10 years in an attempt to identify technical factors, which contribute to improved short-term outcomes. A retrospective review of 92 minimally invasive esophagectomies was performed at the Ochsner Clinic Foundation from 1999 through 2009. Data collected included preoperative stage, whether or not preoperative chemoradiation was used, technique of minimally-invasive resection, technique of esophagogastric anastomosis, margin status, anastomotic leak, conduit necrosis, gastric conduit failure of any type, and operative mortality. Gastric stapling was done either laparoscopically (intracorporeal) or through a minilaparotomy (extracorporeal). Ninety-two patients met criteria for this study. There was a significant difference in the incidence of positive gastric margins (P = 0.04), anastomotic leak (P = 0.045), conduit necrosis (P = 0.03), and any gastric conduit failure (P = 0.02) favoring the extracorporeal group. The overall short-term morbidity and operative mortality with minimally invasive esophagectomy is comparable to the results obtained with open techniques. A relatively simple modification of the operative technique-performing extracorporeal stapling of the gastric conduit-led to a significant reduction in the incidence of gastric conduit failures when compared with the intracorporeal stapling technique.

NSCLC in Louisiana: Thymidylate synthase and pemetrexed therapy.

e18142 Background: To analyze all patients treated for metastatic non-small cell lung cancer (NSCLC) at our institution and identify factors that influence responses and prognosis, including histological subtype, chemotherapy regimen and possibly biomarkers. Methods: Patients with diagnosis of NSCLC were identified by ICD-9 codes using the Institutional Tumor Registry and data was extracted and analyzed. Patient who received pemetrexed as part of their treatment had the specimen stained for thymidylate synthase (TS) expression by immunohistochemistry (IHC). Results: Four hundred and thirty charts were reviewed and 70 identified patients received palliative chemotherapy for metastatic NSCLC at our institution between 2005 and 2007. Median age at diagnosis was 65 years (46-81). Seventy five percent of patients had definitive histology, adenocarcinoma being the most common. The overall response rate (ORR) for first line therapy was 40%, with a median time to progression (TTP) of 5 months. Patients who received either cisplatin or bevacizumab containing regimens appeared to have higher RR and longer TTP. In second line, ORR was 20% and TTP 3 months. Patient who were able to receive combination chemotherapy had higher response rates and longer TTP, as did patients receiving pemetrexed. In these patients, non-squamous histology had significant higher response rates and TS expression by IHC testing is underway to evaluate its potential as a marker for response. Third line chemotherapy and above, even when given to selected patients, was rarely effective. Conclusions: Our data at Ochsner Clinic Foundation appears to correlate with the most recent national data. Efforts should be made in other to identify patient who will respond to specific drugs and TS might be an important predictor of pemetrexed therapy sensitivity. No significant financial relationships to disclose.

David E. Beck, M.D.

Dr. David E. Beck is Chairman of the Department of Colon and Rectal Surgery at the Ochsner Clinic, New Orleans, Louisiana. Dave was born in Geneva, Illinois. He received a BS degree as a distinguished graduate from the United States Air Force Academy and his MD from the University of Miami in Florida. He completed his general surgery residency at Wilford Hall USAF Medical Center at Lackland AFB, Texas. After spending a year as an Air Force general surgeon at a small base in Florida, he completed a fellowship in Colon and Rectal Surgery at the Cleveland Clinic. Dr. Beck then returned to Wilford Hall to serve as the Chief of Colon and Rectal Surgery and eventually as Chairman of the Department of General Surgery. He has also served at the Air Force Surgeon General's consultant in Colon and Rectal Surgery and during the Gulf War was Chief of Surgery at the 81 Contingency Hospital located at Little Rissington, United Kingdom. After leaving active military service in 1993, he joined the colorectal staff at the Ochsner Clinic and in 1995 became chairman of the department in 1997. In 2005, he was elected to the Board of Governors of the Ochsner Clinic.