Role of ablation therapy in conjunction with surgical resection for neuroendocrine tumors involving the liver.

BACKGROUND: Resection of hepatic metastasis from neuroendocrine tumors (NETs) improves quality of life and prolongs 5-year survival. Ablation can be utilized with surgery to achieve complete resection. Although several studies report long-term outcomes for patients undergoing ablation, none have explored perioperative effects of ablation in patients with metastatic NETs. AIM: To determine if intra-operative ablation during hepatectomy increases risk of adverse outcomes such as surgical site infections (SSIs), bleeding, and bile leak. METHODS: A retrospective analysis of the hepatectomy National Surgical Quality Improvement Program database from 2015-2019 was performed to determine the odds of SSIs, bile leaks, or bleeding in patients undergoing intraoperative ablation when compared to hepatectomy alone. RESULTS: Of the 966 patients included in the study, 298 (30.9%) underwent ablation during hepatectomy. There were 78 (11.7%) patients with SSIs in the hepatectomy alone group and 39 (13.1%) patients with a SSIs in the hepatectomy with ablation group. Bile leak occurred in 41 (6.2%) and 14 (4.8%) patients in the two groups, respectively; bleeding occurred in 117 (17.5%) and 33 (11.1%), respectively. After controlling for confounding variables, ablation did not increase risk of SSI (P = 0.63), bile leak (P = 0.34) or bleeding (P = 0.07) when compared to patients undergoing resection alone on multivariate analysis. CONCLUSION: Intraoperative ablation with hepatic resection for NETs is safe in the perioperative period without significant increased risk of infection, bleeding, or bile leak. Surgeons should utilize this modality when appropriate to achieve optimal disease control and outcomes.

Post-operative morbidity after neoadjuvant chemotherapy and resection for gallbladder cancer: A national surgical quality improvement program analysis.

BACKGROUND: Gallbladder cancer is the most common malignancy of the biliary tract. Neoadjuvant chemotherapy (NACT) has improved overall survival by enabling R0 resection. Currently, there is no consensus of guidelines for neoadjuvant therapy in gallbladder cancer. As investigations continue to analyze the regimen and benefit of NACT for ongoing care of gallbladder cancer patients, we examined American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to determine if there was higher morbidity among the neoadjuvant group within the 30-day post-operative period. We hypothesized patients who underwent NACT were more likely to have higher post-operative morbidity. AIM: To investigate the 30-day post-operative morbidity outcomes between patients who received NACT and underwent surgery and patients who only had surgery. METHODS: A retrospective analysis of the targeted hepatectomy NSQIP data between 2015 and 2019 was performed to determine if NACT in gallbladder cancer increased the risk for post-operative morbidity (bile leak, infection rate, rate of converting to open surgery, etc.) compared to the group who only had surgery. To calculate the odds ratio for the primary and secondary outcomes, a crude logistic regression was performed. RESULTS: Of the 452 patients, 52 patients received NACT prior to surgery. There were no statistically significant differences in the odds of morbidity between the two groups, including bile leak [odds ratio (OR), 0.69; 95% confidence interval (95%CI): 0.16-2.10; P = 0.55], superficial wound infection (OR, 0.58; 95%CI: 0.03-3.02; P = 0.61), and organ space wound infection (OR, 0.63; 95%CI: 0.18-1.63; P = 0.61). CONCLUSION: There was no significant difference in the risk of 30-day post-operative morbidity between the NACT and surgery group and the surgery only group.

Radiation therapy prior to a pancreaticoduodenectomy for adenocarcinoma is associated with longer operative times and higher blood loss.

BACKGROUND: Pancreatic adenocarcinoma is currently the fourth leading cause of cancer-related deaths in the United States. In patients with "borderline resectable" disease, current National Comprehensive Cancer Center guidelines recommend the use of neoadjuvant chemoradiation prior to a pancreaticoduodenectomy. Although neoadjuvant radiotherapy may improve negative margin resection rate, it is theorized that its administration increases operative times and complexity. AIM: To investigate the association between neoadjuvant radiotherapy and 30-d morbidity and mortality outcomes among patients receiving a pancreaticoduodenectomy for pancreatic adenocarcinoma. METHODS: Patients listed in the 2015-2019 National Surgery Quality Improvement Program data set, who received a pancreaticoduodenectomy for pancreatic adenocarcinoma, were divided into two groups based off neoadjuvant radiotherapy status. Multivariable regression was used to determine if there is a significant correlation between neoadjuvant radiotherapy, perioperative blood transfusion status, total operative time, and other perioperative outcomes. RESULTS: Of the 11458 patients included in the study, 1470 (12.8%) underwent neoadjuvant radiotherapy. Patients who received neoadjuvant radiotherapy were significantly more likely to require a perioperative blood transfusion [adjusted odds ratio (aOR) = 1.58, 95% confidence interval (CI): 1.37-1.82; P < 0.001] and have longer surgeries (insulin receptor-related receptor = 1.14, 95%CI: 1.11-1.16; P < 0.001), while simultaneously having lower rates of organ space infections (aOR = 0.80, 95%CI: 0.66-0.97; P = 0.02) and pancreatic fistula formation (aOR = 0.50, 95%CI: 0.40-0.63; P < 0.001) compared to those who underwent surgery alone. CONCLUSION: Neoadjuvant radiotherapy, while not associated with increased mortality, will impact the complexity of surgical resection in patients with pancreatic adenocarcinoma.

Concurrent major hepatic resection with primary colorectal cancer increases risk of organ space infections.

INTRODUCTION: Patients with colorectal cancer frequently present with liver metastases requiring either concurrent colon and liver resection or staged resection for curative therapy. The goal of this study is to determine if synchronous resection increases risk of perioperative adverse outcomes such as surgical site infections (SSIs). METHODS AND PROCEDURES: We conducted a cross-sectional retrospective analysis of the targeted hepatectomy NSQIP database from 2015 to 2019. The primary outcome was surgical site infections stratified into superficial, deep, organ space, and wound dehiscence. We performed univariate followed by a multivariate logistic regression to determine if there were higher odds of SSIs in patients undergoing hepatic resection concurrently with primary colorectal resection. Additionally, we performed stratified analyses by size of hepatic resections (partial, total left, total right, and trisegmentectomy). RESULTS: Of the 7,445 patients included in the study, 431(5.8%) underwent synchronous resection and 7,014 metachronous resection. On average, synchronous resections prolonged surgery by 62 min. There was no difference in superficial and deep SSIs between the groups; however, there was a significant difference in organ space SSIs. Patients undergoing synchronous resection had 1.51 times the odds of developing an organ space SSI (OR 1.51, 95%CI 1.10, 2.17, p = 0.04) compared to patients with metachronous resection on multivariate analysis. Patients undergoing a total right hepatectomy concurrently with a colorectal resection had 2.30 times the odds of developing an organ space SSI (OR 2.30, 95%CI 1.20, 6.86, p = 0.010). CONCLUSIONS: Prior studies demonstrated that synchronous resections are safe in properly selected patients with no difference in long-term outcomes. Few studies have explored immediate perioperative outcomes between the two approaches. After controlling for confounders, we demonstrate that synchronous resection with major hepatic surgery increases the risk of organ space SSIs. Future studies should elucidate the precise source of organ space SSIs in order to decrease the risk of this adverse outcome.

Challenging Orthodoxy: beyond the Critical View of Safety.

BACKGROUND: The critical view of safety (CVS) is the gold standard for performing safe cholecystectomies and minimizing common bile duct (CBD) injuries. It requires three criteria: complete clearance of the hepatocystic triangle, partial separation of the gallbladder from the cystic plate, and two structures alone entering the gallbladder. However, biliary anatomy varies widely, with frequent aberrant arterial supplies, which can mislead or disorient those attempting to acquire the CVS. This study was designed to examine the nature and frequency of cystic artery anatomic anomalies. METHODS: We conducted a prospective observational study from 2018 to 2020, compiling photos of the critical view of safety of 100 consecutive elective cholecystectomies performed at our institution. Gallbladders were dissected up to the parallel portion of the cystic plate to achieve a critical view of safety. All tubular structures were preserved and clipped. Operative reports were examined for mention of posterior cystic arteries or aberrant arterial supplies. Photos were reviewed for an adequate critical view of the safety and presence of aberrant arterial supplies. The rate of aberrant arterial supply was determined and photos were reviewed for patterns of common abnormalities. RESULTS: There were 121 patients who underwent an elective cholecystectomy; 21 lacked intraoperative pictures and were excluded from the study. Of the 100 patients included, 57 (57%) had an aberrant arterial supply with more than one cystic artery; seven had three concurrent arteries. Of those with more than one cystic artery, 21% had a recurrent cystic artery, 21% had a posterior dominant cystic artery, and 12% had a low-branching anterior cystic artery. CONCLUSION: Even with appropriate dissection for the CVS, surgeons can expect to frequently visualize more than two structures entering the gallbladder when a posterior cystic artery is present. It is, therefore, integral to distinguish this aberrant anatomy to prevent inadvertent injury to the CBD.

Endoluminal vacuum therapy for rectal anastomosis is safe and does not increase risk of strictures in a swine model.

Background: Endoluminal vacuum therapy has been experimentally used in patients with esophageal, rectal, and Roux-en-Y bypass surgery. Yorkshire pigs are good animal models for studying the safety and efficacy of endoluminal vacuum therapy and prior studies have employed these devices in rectal anastomotic defects, as rescue therapy for early anastomotic leaks, as well as prophylactic therapy as a means of protecting high risk anastomosis. Aim: The objective of this study is to assess the effects of a prophylactic vacuum assist device on bowel tissue surrounding an intact anastomosis at 30 days post device removal. Methods: A total of seven pigs underwent a rectal resection with primary anastomosis: five experimental pigs with a prophylactic endoluminal vacuum device in place for 5 days post-surgery and two control pigs with no device. All animals were euthanized on the 35th post-operative day and subjected to a necropsy with a histopathological evaluation of the rectal anastomosis. Results: No significant difference in inflammation or strictures was observed between the anastomosis of animals with the endoluminal vacuum devices and controls. Conclusion: We, therefore, conclude that endoluminal vacuum therapy is safe for prophylactic use in pigs undergoing low anterior resection and does not cause significant strictures. Relevance for Patients: Anastomotic leak is a feared complication resulting in increased costs, length of stay, and emotional distress. Endoluminal negative pressure vacuum therapy is a new technology that has been used in experimental models in both animals and humans for prevention and treatment of anastomotic leak. In this series we demonstrate endoluminal vacuum therapy is safe in a porcine model and does not result in stricture or increased adhesion formation. We expect endoluminal vacuum therapy to become more widely used in the future in both prevention and treatment of anastomotic leaks.

Prolonged lower extremity endovascular procedures for patients with claudication increase risk of adverse outcomes.

OBJECTIVE: Historically, longer operative times for open infrainguinal revascularization have been associated with higher perioperative complication rates, especially surgical site infections and extended lengths of stay. We sought to determine whether an association existed between the procedure length and morbidity or mortality after elective lower extremity endovascular interventions. METHODS: We conducted a cross-sectional retrospective analysis of the targeted lower extremity National Surgery Quality Improvement Program database from 2012 to 2017. We included patients who had been either asymptomatic or had presented with claudication. The primary outcome was a severe adverse outcome, including one or more of the following: death, myocardial infarction, amputation, bleeding, and cerebrovascular accident. We performed univariate logistic regression analysis to determine whether patients with longer operative times had had greater odds of experiencing a severe adverse outcome. We performed a multivariate analysis using a logistic regression model to identify variables predictive of the outcome of interest. RESULTS: A total of 4081 patients were included, 3478 with claudication and 603 without symptoms. Patients with unknown disease or critical limb ischemia were excluded. Of the 4081 patients, 3646 had undergone interventions in the femoropopliteal region (89.3%) and 406 in the tibial region (10.0%). For the remaining 29 patients, the location of the endovascular intervention was missing. The median operative time for all procedures was 84 minutes. On univariate analysis, an operative time >121 minutes was a significant predictor of a severe adverse outcome (P < .0001). We used a forward selection method to identify confounders and subsequently performed multivariate logistic regression. Even after controlling for confounders, an operative time >121 minutes remained a significant predictor of severe adverse outcomes. CONCLUSIONS: For patients with claudication and asymptomatic patients, prolonged operative times for elective endovascular procedures were associated with poor outcomes. After controlling for confounders, we found a statistically significant association between the procedure length and the occurrence of adverse outcomes. Specifically, an operating time >2 hours had had significantly greater odds of dying or experiencing myocardial infarction, amputation, or bleeding. Thus, surgeons should weigh the benefits and choice of endovascular intervention types against the risks of prolonged procedures.

The Rise and Fall of Percutaneous Cholecystostomy in a Community Hospital: Is It Possible to Turn the Tide of History?

BACKGROUND: Laparoscopic cholecystectomy is the gold standard for treatment of acute cholecystitis. Percutaneous cholecystostomy (PC) drains are alternatives to cholecystectomy in critically ill patients in whom surgery carries an unacceptably high risk. Recently, several studies demonstrated a significant increase in complications in patients undergoing PC in comparison to laparoscopic cholecystectomy. METHODS: We conducted a retrospective analysis of patients who underwent PC drainage or cholecystectomy from 2014 through 2019 at our institution. We determined the rate of PC use and performed a linear regression analysis to evaluate PC utilization over time. After creating institutional guidelines and reeducating physicians on appropriate use of PC drainage in 2019, we compared PC utilization to prior years. RESULTS: A total of 146 PCs and 3163 cholecystectomies were performed over the study period. Of the cholecystectomies, 754 (23.8%) were performed in hospitalized patients under urgent or emergent conditions. Of the patients with acute cholecystitis, 16.2% were treated with PC. Linear regression analysis demonstrated a significant association between year and rate of PC procedures (p<0.001). The rate of PC rose from 13.8 to 22.5% between 2014 and 2018 and dropped to 10.9% (p=0.006) in 2019 after the reeducation program. CONCLUSIONS: With a rising rate of PC utilization and in light of recent studies suggesting increased complications and healthcare costs for patients undergoing this procedure, care needs to be taken to ensure that only appropriate patients are referred for PC. Publication of institutional guidelines, resident and attending surgeon reeducation, and case review can reduce placement of unnecessary PCs.

Operating-Room Procedures Do Not Increase Risk of COVID-19 Infection.

BACKGROUND AND OBJECTIVES: Operating-room procedures canceled due to the COVID-19 pandemic depleted hospital revenue and potentially worsened patient outcomes through disease progression. Despite safeguards to resume elective procedures, patients remain apprehensive of contracting COVID-19 during hospitalization and recovery. We investigated symptomatic COVID-19 infection in patients undergoing operating-room procedures during the spring 2020 outbreak in Fairfield County, CT, a heavily affected New York Metropolitan area. METHODS: We retrospectively analyzed 419 operating-room patients in Danbury and Norwalk Hospitals between 3/16/20 and 5/19/20. COVID-19 infection was assessed through test results or documented well-being within 2 weeks postdischarge. Variables studied were procedure classification, length of stay, and discharge disposition. Postprocedural COVID-19 infection was analyzed using binomial tests comparing rates to state-mandated infection data. RESULTS: Six patients developed COVID-19 after 212 urgent-elective and 207 emergent procedures. Overall postprocedural infection risk was equivalent to community infection risk (P > .05). No infections occurred in 1-2 day stays or urgent-elective procedures with discharge home (both P < .05). Discharges home reduced the risk to one-sixth of community spread (P = .03). Risk of infection doubled in hospitalizations > 5 days (P = .05) and quadrupled in discharges to extended care facilities (P = .01). DISCUSSION: Operating-room procedures did not increase the risk of symptomatic COVID-19 infection during an outbreak. Urgent-elective and emergent procedures during further outbreaks appear safe when anticipating short stays with discharges home. When anticipating prolonged hospitalization or discharges to facilities, appropriate delay of urgent-elective procedures may minimize risk of infection.

Racial Disparities and Upward Trend in Bowel Preparation for Elective Colectomy in the National Surgical Quality Improvement Program Procedure Targeted Dataset: 2012 to 2018.

Objective: The primary objective of this study was to assess trends in bowel preparation among patients who had elective colectomy between 2012 and 2018. The secondary objective was to assess patient and procedure-related factors predictive of bowel preparation use or lack thereof. Background: Numerous studies have demonstrated that bowel preparation before elective colorectal surgery can reduce the risk of postoperative complications. Studies of surgeon practices found 75% to 98% prescribe bowel preparation to their patients, although biases in the study design may lead to overestimation of bowel preparation practice. Methods: Cross-sectional study of the National Surgical Quality Improvement Program colectomy procedure targeted dataset. We included patients from 18 to 90 years old who underwent elective colectomy (n = 101,096). The primary outcomes were bowel preparation before elective colectomy, including oral antibiotic only, mechanical only, both oral and mechanical, or none. Results: Twenty percent of patients did not do any bowel preparation before elective colectomy. Almost all covariates were independently associated with any bowel preparation, although some were not clinically relevant. The odds that Black/African American or Hispanic patients had any bowel preparation were lower than that of White patients. Additionally, the odds minimally invasive colectomy patients completed any bowel preparation was 1.46 times that of open surgery patients. Conclusions: This study is the first of its kind to assess trends in bowel preparation using an objective dataset. Our study highlights disparities in bowel preparation. Further studies should focus on delineating the root cause of this disparity, identifying the barriers, and finding solutions.

Impacts on Surgery Resident Education at a First Wave COVID-19 Epicenter.

PURPOSE: This study aims to identify the effects of the COVID-19 pandemic on surgical resident training and education at Danbury Hospital. METHODS: We conducted an observational study at a Western Connecticut hospital heavily affected by the first wave of the COVID-19 pandemic to assess its effects on surgical residents, focusing on surgical education, clinical experience, and operative skills development. Objective data was available through recorded work hours, case logs, and formal didactics. In addition, we created an anonymous survey to assess resident perception of their residency experience during the pandemic. RESULTS: There are 22 surgical residents at our institution; all were included in the study. Resident weekly duty hours decreased by 23.9 hours with the majority of clinical time redirected to caring for COVID-19 patients. Independent studying increased by 1.6 hours (26.2%) while weekly didactics decreased by 2.1 hours (35.6%). The operative volume per resident decreased by 65.7% from 35.0 to 12.0 cases for the period of interest, with a disproportionately high effect on junior residents, who experienced a 76.2% decrease. Unsurprisingly, 70% of residents reported a negative effect of the pandemic on their surgical skills. CONCLUSIONS: During the first wave of the COVID-19 pandemic, surgical residents' usual workflows changed dramatically, as much of their time was dedicated to the critical care of patients with COVID-19. However, the consequent opportunity cost was to surgery-specific training; there was a significant decrease in operative cases and time spent in surgical didactics, along with elevated concern about overall preparedness for their intended career.

Has COVID-19 Hurt Resident Education? A Network-Wide Resident Survey on Education and Experience During the Pandemic.

PURPOSE: As the COVID-19 pandemic continues to evolve, the healthcare system has been forced to adapt in myriad ways. Residents have faced significant changes in work schedules, deployment to COVID-19 units, and alterations to didactics. This study aims to identify the effects of the COVID-19 pandemic on resident perception of their own education within the Nuvance Health Network. METHODS: We conducted an observational study assessing resident perception of changes in education and lifestyle during the COVID-19 pandemic. A survey was developed to assess the quality and quantity of resident education during this time and administered anonymously to all residents within the healthcare network. RESULTS: Eighty-four (68%) residents responded to the survey from 5 different specialties, including general surgery, internal medicine, obstetrics and gynecology, pathology, and radiology. The average change in hours per week performing clinical work was -6 hours (SD = 17; P = .003), in time studying was +0 hours (SD = 5; P = .96), in weekly didactics was -2 hours (SD = 3; P < .001), and in attending involvement was -1 hours (SD = 2; P < .001). Additionally, 32% of residents expressed concern that the pandemic has diminished their preparedness to become an attending, 13% expressed concern about completing graduation requirements, and 3% felt they would need an additional year of training. CONCLUSION: During the COVID-19 pandemic thus far, residents perceived that time spent on organized didactics/conferences decreased and that attending physicians are less involved in education. Furthermore, the majority of residents felt that the quality of didactic education diminished as a result of the pandemic. Surprisingly, while many residents expressed concerns about being prepared to become an attending, few were concerned about completing graduation requirements or needing an extra year of education. In light of these findings, it is critical to devote attention to the effects of the pandemic on residents' professional trajectories and create innovative opportunities for improving education during this challenging time.

Accuracy of Ultrasound in Diagnosing Gallbladder Polyps at a Community Hospital.

BACKGROUND AND OBJECTIVES: Polyps are reported on 1-10% of routine transabdominal ultrasound studies of the gallbladder. Prior studies have reported poor sensitivity and specificity for this diagnostic modality at determining malignant potential of polyps. The aim of this study is to determine the incidence of gallbladder polyps documented on ultrasound at a community hospital, evaluate the congruency of ultrasound with final histopathology, and explore factors which may improve ultrasound accuracy at diagnosing true adenomatous polyps. METHODS: We conducted a 5-year retrospective cohort study of patients undergoing cholecystectomy at Danbury Hospital between 2014 and 2019, identifying those with a pre-operative ultrasound mention of a "polyp" or "mass." We assessed the congruency of ultrasound findings with pathology reports. RESULTS: Of the 2,549 cholecystectomies performed, 1,944 (76%) had pre-operative ultrasounds. Of those, 98 (5.0%) reported a polyp, measuring an average of 8.1 mm (SD 7.1 mm). Three (3.1%) specimens were identified as adenomas on final histopathology; the majority were benign pathologies including cholesterol polyp (18), cholesterolosis (20), adenomyoma (4), adenomyomatosis (7), and chronic or acute cholecystitis (44). Interestingly, only 1 of the 3 adenomas measured > 10 mm on ultrasound, the accepted indication for surgical resection. CONCLUSIONS: The accuracy of transabdominal ultrasound in diagnosing true polyps is poor, with only 3% of polyps identified as adenomas based on pathology. Surgeons should use caution when making clinical decisions based on polyps identified on ultrasound, and more stringent diagnostic criteria are needed in order to decrease the false positive rate for diagnosis and screening.

Rare Case of Acute Type B Dissection Causing Complete Collapse of EVAR Stent.

We describe a unique case of an acute type B aortic dissection in a patient with a history of a previously placed infrarenal aortic stent for an abdominal aortic aneurysm. The patient presented with a hypertensive emergency and left lower extremity ischemia, and imaging revealed complete collapse of the previously placed stent graft with extension into the iliac limbs. He underwent emergent endovascular intervention. When the false lumen was entered by puncturing the dissection plane with a sheath, immediate reexpansion of the stent graft was observed. The entry point of the dissection was covered with 2 overlapping stents, restoring flow within the true lumen. Although aortic stent collapse from acute type B aortic dissections is extremely rare, we demonstrate that endovascular release of the outflow obstruction and depressurizing the false lumen can resolve this dreaded complication.

Evolution of H3K27me3-marked chromatin is linked to gene expression evolution and to patterns of gene duplication and diversification.

Histone modifications are critical for the regulation of gene expression, cell type specification, and differentiation. However, evolutionary patterns of key modifications that regulate gene expression in differentiating organisms have not been examined. Here we mapped the genomic locations of the repressive mark histone 3 lysine 27 trimethylation (H3K27me3) in four species of Drosophila, and compared these patterns to those in C. elegans. We found that patterns of H3K27me3 are highly conserved across species, but conservation is substantially weaker among duplicated genes. We further discovered that retropositions are associated with greater evolutionary changes in H3K27me3 and gene expression than tandem duplications, indicating that local chromatin constraints influence duplicated gene evolution. These changes are also associated with concomitant evolution of gene expression. Our findings reveal the strong conservation of genomic architecture governed by an epigenetic mark across distantly related species and the importance of gene duplication in generating novel H3K27me3 profiles.

Diverse patterns of genomic targeting by transcriptional regulators in Drosophila melanogaster.

Annotation of regulatory elements and identification of the transcription-related factors (TRFs) targeting these elements are key steps in understanding how cells interpret their genetic blueprint and their environment during development, and how that process goes awry in the case of disease. One goal of the modENCODE (model organism ENCyclopedia of DNA Elements) Project is to survey a diverse sampling of TRFs, both DNA-binding and non-DNA-binding factors, to provide a framework for the subsequent study of the mechanisms by which transcriptional regulators target the genome. Here we provide an updated map of the Drosophila melanogaster regulatory genome based on the location of 84 TRFs at various stages of development. This regulatory map reveals a variety of genomic targeting patterns, including factors with strong preferences toward proximal promoter binding, factors that target intergenic and intronic DNA, and factors with distinct chromatin state preferences. The data also highlight the stringency of the Polycomb regulatory network, and show association of the Trithorax-like (Trl) protein with hotspots of DNA binding throughout development. Furthermore, the data identify more than 5800 instances in which TRFs target DNA regions with demonstrated enhancer activity. Regions of high TRF co-occupancy are more likely to be associated with open enhancers used across cell types, while lower TRF occupancy regions are associated with complex enhancers that are also regulated at the epigenetic level. Together these data serve as a resource for the research community in the continued effort to dissect transcriptional regulatory mechanisms directing Drosophila development.