Background: Entero-atmospheric fistula (EAF) is a devastating rare complication after abdominal s... more Background: Entero-atmospheric fistula (EAF) is a devastating rare complication after abdominal surgery. When parenteral feeding is not feasible, an enteral feeding access must be obtained. A Trans-Fistula Percutaneous Endoscopic Jejunostomy (TF-PEJ) approach is presented. Case presentation: A young male that underwent emergent pancreatoduodenectomy developed three complicated proximal EAF, following multiple laparotomies and an open abdomen approach. Oral feeding was unsuccessful due to considerable fistulae drainage. Liver insufficiency led to total parenteral nutrition (TPN) discontinuation. TF-PEJ was inserted for nutritional support. Conclusion: After the TF-PEJ insertion, the patient recuperated and was discharged home, currently he is awaiting definitive treatment. A TF-PEJ is a creative solution for feeding patients with a proximal fistula.
Background Patient attendance at emergency departments (EDs) during the COVID-19 pandemic outbrea... more Background Patient attendance at emergency departments (EDs) during the COVID-19 pandemic outbreak has decreased dramatically under the "stay at home" and "lockdown" restrictions. By contrast, a notable rise in severity of various surgical conditions was observed, suggesting that the restrictions coupled with fear from medical facilities might negatively impact non-COVID-19 diseases. This study aims to assess the incidence and outcome of complicated appendicitis (CA) cases during that period. Methods A retrospective study comparing the rate and severity of acute appendicitis (AA) cases during the COVID-19 initial outbreak in Israel during March and April of 2020 (P20) to the corresponding period in 2019 (P19) was conducted. Patient data included demographics, pre-ED status, surgical data, and postoperative outcomes. Results Overall, 123 patients were diagnosed with acute appendicitis, 60 patients during P20 were compared to 63 patients in P19. The rate of complicated appendicitis cases was significantly higher during the COVID-19 Lockdown with 43.3% (26 patients) vs. 20.6% (13 patients), respectively (p < 0.01). The average delay in ED presentation between P20 and P19 was 3.4 vs. 2 days (p = 0.03). The length of stay was 2.6 days in P20 vs. 2.3 days in P19 (p = 0.4), and the readmission rate was 12% (7 patients) vs. 4.8% (3 patients), p = 0.17, respectively. Logistic regression demonstrated that a delay in ED presentation was a significant risk factor for complicated appendicitis (OR 1.139, CI 1.011-1.284). Conclusion The effect of the COVID-19 initial outbreak and Lockdown coupled with hesitation to come to medical facilities appears to have discouraged patients with acute appendicitis from presenting to the ED as complaints began, causing a delay in diagnosis and treatment, which might have led to a higher rate of complicated appendicitis cases and a heavier burden on health care systems.
Background: In colorectal cancer, CRP levels on postoperative days 3-4 have a strong negative pre... more Background: In colorectal cancer, CRP levels on postoperative days 3-4 have a strong negative predictive value for an anastomotic leak, with threshold values of ~15 on POD 3 and ~13 on POD 4. In Crohn’s disease, CRP levels are perceived as unreliable in the postoperative period because of the underlying inflammatory process. The aim of this study was to investigate the use of postoperative CRP levels in patients with Crohn’s Disease and set threshold values for this population. Methods: This is a retrospective study of the medical records of adult patients with Crohn’s Disease who underwent bowel anastomoses, at a single, high volume center. The operations were performed by a single colorectal consultant who is an inflammatory bowel disease specialist, between 1/2012 and 12/2017. Results: 92 operations were performed. Mean CRP levels and CRP threshold values were higher in the study’s population compared with studies on colorectal cancer patients. A CRP level of 19.56 mg\dL on posto...
Locally advanced rectal cancer dictates a major surgical undertaking, which includes en bloc rese... more Locally advanced rectal cancer dictates a major surgical undertaking, which includes en bloc resection of the rectum and all involved organs. The aim of this study was to evaluate patient outcome and compare multimodality treatment options after various surgical approaches from one institution for T4 rectal cancer. A retrospective chart review identified 24 patients who were operated on for advanced primary rectal cancer invading adjacent structures (T4) over a 5½-year period. The types of treatment and outcome were analyzed. From these 24 patients, the most frequently involved organ was the bladder (33%). A total of 16 patients underwent chemoradiotherapy. There were 12 complications (50%), the most common being wound infection (33% of complications, 17% overall). Nine patients had nodal disease. Disease-free survival was 54 per cent, and overall survival was 75 per cent. However, disease-free survival in node-negative patients was 67 per cent versus 33 per cent in node-positive in...
Cancer-associated fibroblasts of the stroma play a major role in tumor promoting processes. In th... more Cancer-associated fibroblasts of the stroma play a major role in tumor promoting processes. In this study we evaluated the significance of Phospholipase D (PLD) enzyme activity in promoting human colon cancer malignant potency when interacting with proximal colonic fibroblasts. Human colon cancer cell lines SW480 and HCT116, and colonic fibroblasts CCD-18Co were used as an in vitro model. PLD's activity was measured in resting cancer cells and after culturing with fibroblasts and cancer-associated fibroblasts (CAFs) conditioned medium. The viability and migration level of the cancer cells alone and after co-culturing with fibroblast or CAFs conditioned medium were evaluated, with and without adding a PLD inhibitor. Exposure of colon cancer cells to CAFs conditioned medium significantly increased the level of PLD activity in the cancer cells (p<0.0001). Exposure of colon cancer to resting and activated fibroblast conditioned medium significantly enhanced the number of viable c...
International Journal of Surgery Case Reports, 2017
INTRODUCTION: Postoperative small bowel obstruction due to intussusception is a rare entity but c... more INTRODUCTION: Postoperative small bowel obstruction due to intussusception is a rare entity but can lead to severe morbidity and even mortality. We present a case of this rare complication produced by an unusual cause. CASE REPORT: A 22 year old male, who is a fruitarian, presented to the E.R on day 6 after laparotomy due to obstructing fetobezors that were removed via gastrotomy and enterotomy. In his readmission, he had severe, diffuse abdominal pain, distended abdomen and diffuse peritonitis. Abdominal computed tomography (CT) showed a large amount of fluid in the abdomen, distended small bowel loops, a small amount of free air around the stomach and a suspected ileo-ileal intussusception. The patient underwent emergent laparotomy which revealed an ileo-ileal intussusception with the sutured enterotomy site from the previous operation as the lead point. In addition, a minor dehiscence of the gastrotomy site was identified. A reduction of the intussusception was performed with resection of the enterotomy site and side to side anastomosis. The gastrotomy site was debrided and re-sutured. Recovery was uneventful. CONCLUSION: Postoperative intussusception, although rare, is potentially a dangerous complication, often not involving the site of the primary operation. To our knowledge this is the first report of an intussusception with a sutured enterotomy site as the lead point. Clinicians should be aware of this entity when assessing a patient with abdominal pain and distention after surgery with enterotomy or resection of bowel.
Anastomotic leak after colorectal surgery is a severe complication leading to major postoperative... more Anastomotic leak after colorectal surgery is a severe complication leading to major postoperative morbidity and mortality. Leaks typically present on the 5th to 6th postoperative days; however, early anastomotic dehiscence occurs occasionally. This study evaluated carcinoembryonic antigen (CEA) levels in abdominal drains after colorectal resection to assess its potential as an early marker to predict anastomotic leaks. This prospective study included 105 patients undergoing elective colorectal surgery. Fluids from the patients&amp;amp;#39; abdominal drain system were sampled daily for up to 3 days after surgery and evaluated for CEA levels. Early anastomotic dehiscence occurred in 3 patients (2.8%) and was associated with a significant elevation of CEA in drain fluids (above 1,000 ng/mL). However, in patients who developed late leaks (7 patients, 6.7%) no significant elevation of CEA was observed. Significant elevation of CEA levels in abdominal drains in the early postoperative period may indicate early anastomotic dehiscence.
Background.Clinical data and animal models support an association between postoperative inflammat... more Background.Clinical data and animal models support an association between postoperative inflammatory response and the risk of colorectal cancer recurrence. Our aim was to evaluate postoperative peritoneal inflammation and its impact on cultured colon cancer cells’ migration capacity.Methods.23 patients undergoing elective colorectal resection with uneventful recovery were prospectively enrolled. Patients were operated on for both malignant and benign etiologies. Peritoneal fluids collected at surgery initiation and after surgery were evaluated for their effect on migration potential of human colon cancer cells using anin vitroscratch assay and on TNF-α, IL-1β, IL-6, and IL-10 levels using bead-based fluorokine-linked multianalyte profiling.Results.Postoperative peritoneal fluid from all patients increased the migration capacity of colon cancer cells compared to preoperative levels. This effect was significant during the first two postoperative days and decreased thereafter. The incr...
Weight loss in morbidly obese patients is associated with changes in thyroid function. Studies ha... more Weight loss in morbidly obese patients is associated with changes in thyroid function. Studies have demonstrated equivalent changes following bariatric surgery. Changes in thyroid function were reported following laparoscopic Roux-en-Y gastric bypass (LRYGB), biliopancreatic diversion (BPD), and laparoscopic adjustable gastric banding (LAGB). No data exists on changes in thyroid function following laparoscopic sleeve gastrectomy (LSG). The aim of the current study is to evaluate changes in thyroid function following LSG in patients with normal thyroid function. Data were retrieved from a prospectively collected database of patients who underwent LSG for morbid obesity. Euthyroid patients were evaluated for changes in TSH and free thyroxine (FT4), 6-12 months after surgery. Correlation between changes in thyroid hormone levels, excess weight loss (EWL), and baseline TSH were evaluated. Thirty-eight patients were included in the study. Mean BMI decreased from 42.4 to 32.5 kg/m(2) (P &...
Peritoneal carcinoembryonic antigen (pCEA) levels in the early postoperative period following a c... more Peritoneal carcinoembryonic antigen (pCEA) levels in the early postoperative period following a curative resection of colorectal cancer (CRC) have not been previously studied. Postoperative peritoneal fluids of 36 CRC patients followed by 24 benign colonic disease patients were evaluated for CEA levels and tumor cell presence. Serum CEA levels were also evaluated prior and after surgery. Although high postoperative pCEA levels were observed in some benign patients, more CRC patients exhibited significant elevation of postoperative pCEA (>5 ng/ml) compared to benign patients (50% vs. 23%, P = 0.039). Postoperative median pCEA levels of CRC patients were significantly higher compared to benign patients (5.4 vs. 2 ng/ml, P = 0.011). Specifically, pCEA levels in CRC patients were significantly elevated when measured during the first 24 hr after surgery. Postoperative pCEA levels were associated with colon tumor location compared to rectal location. However, no correlation was found w...
The Israel Medical Association journal : IMAJ, 2011
Major changes in the evaluation and treatment of curable colorectal cancer (CRC) have emerged in ... more Major changes in the evaluation and treatment of curable colorectal cancer (CRC) have emerged in the last two decades. These changes have led to better patient outcome overtime. To evaluate the impact of these changes as reflected in the difference in long-term outcome of a consecutive group of recently laparoscopically operated curable CRC patients and a consecutive group of patients operated 20 years earlier in the same department. Data of the new group were taken from our prospectively collected data of patients who underwent elective laparoscopic surgery for CRC in recent years. Data regarding patients operated on 20 years ago were retrieved from previous prospectively collected data on the long-term survival of CRC patients operated in the same department. The recently operated group comprised 203 patients and the previous group 199 patients. Perioperative mortality was 0.5% in the new group versus 1.5% in the old group (not significant). There were more early-stage and more pr...
The Israel Medical Association journal : IMAJ, 2011
The effect of anti-platelet drugs on surgical blood loss and perioperative complications has not ... more The effect of anti-platelet drugs on surgical blood loss and perioperative complications has not been studied in depth and the management of surgical patients taking anti-platelet medications is controversial. To assess the effect of anti-platelet therapy on perioperative blood loss in patients undergoing appendectomy either laparoscopically or via open surgery. We reviewed the files of all patients 40 years old who underwent open or laparoscopic appendectomies from 2007 to 2010. Excluded were patients with short hospitalization and no follow-up of hemoglobin level, patients on warfarin treatment and patients who underwent additional procedures. Estimation of blood loss was based on decrease in hemoglobin level from admission to discharge. Risk factors for blood loss, such as anti-platelet therapy, age, gender, surgical approach, surgical time, surgical findings and complications, were analyzed. The final cohort included 179 patients (mean age 61 +/- 14 years, range 40-93) of whom 6...
The Israel Medical Association journal : IMAJ, 2011
Esophageal perforations and postoperative esophageal leaks are associated with substantial morbid... more Esophageal perforations and postoperative esophageal leaks are associated with substantial morbidity and mortality and pose a difficult therapeutic challenge. Toevaluate the outcome ofremovableself-expanding metallic stents (SEMS) as a treatment for postoperative leaks and perforations of the esophagus and stomach. We conducted a retrospective study of all patients in one medical center who underwent temporary insertion of a covered plastic stent for postoperative leaks and perforations of the esophagus and stomach from June 2009 to February 2010. Data were retrieved from hospital and outpatient clinical data charts. Data included indication for insertion, post-insertion outcome including stent complications, and follow-up after stent removal. The indications for stent insertion were postoperative leak in four patients and postoperative esophagopleural fistula in one patient. Three of the patients had a leak at the gastroesophageal junction following laparoscopic sleeve gastrectomy....
Background: Traditional esophagectomy may be associated with mortality, considerable morbidity, a... more Background: Traditional esophagectomy may be associated with mortality, considerable morbidity, and lengthy recovery. It is often performed in cancer patients who are typically older, have associated comorbidities, and are often malnourished, all factors that increase surgical risk. Minimally invasive esophagectomy has the potential advantages of being a less traumatic procedure with an easier postoperative recovery and fewer wound and pulmonary complications. Methods: A retrospective analysis of patients who underwent laparoscopic transhiatal esophagectomy was performed. Assessed parameters included patient demographics and operative data, pathology results, and long-term follow-up of at least 12 months. Results: Twenty-two patients underwent laparoscopic transhiatal esophagectomy; 19 had esophageal cancer. Two patients were operated on for Barrett esophagus, and 1 patient had achalasia. The majority of patients were men (82%), and the mean age was 59 years (range 15 to 74 years); 1 patient (4.5%) was converted to open surgery. The average operative time was 380 minutes (range 285 to 525 minutes), and the average blood loss was 220 mL; only 3 patients required transfusion. The median hospital stay was 8 days (range 5 to 46 days). Postoperative mortality occurred in 1 patient (4.5%), and postoperative complications developed in 6 patients (27.2%). In the 19 cancer patients, the average number of harvested nodes was 14.3 (range 10 to 19). The average follow-up was 30 months (range 12 to 48 months). The overall survival for cancer patients was 61% (11 of 19), and disease-free survival was 39% (7/19). Conclusions: Esophagectomy is a major surgery with considerable morbidity and potential mortality. Minimally invasive esophagectomy is a feasible approach that can be safely performed by surgeons with extensive experience in that field. Advantages include less intraoperative blood loss, a smaller incision, and a potentially faster postoperative recovery. In cancer patients, immediate oncologic goals of adequate margins and lymph node dissection can be achieved, and long-term outcome appears to be similar to that found with open approaches.
Introduction Many studies have reported on the effects of pneumoperitoneum in a rat model, using ... more Introduction Many studies have reported on the effects of pneumoperitoneum in a rat model, using a wide range of intra-abdominal pressures. The correlation between pneumoperitoneal pressures in rodents to pressures in humans has not been established. This study evaluates changes in various physiological parameters in different pneumoperitoneum pressures in the rat model with a comparison to known data in humans. Materials and methods Three groups of eight Wistar rats each were anesthetized, tracheostomized, and mechanically ventilated with fixed tidal volume and respiratory rate. After a stabilization phase, CO 2 pneumoperitoneum was established to 12, 8, and 5 mmHg in the different groups. Changes in blood pressure, heart rate, peak ventilatory pressure, and end-tidal CO 2 (ETCO 2) were recorded throughout the experiment. Results There were no significant changes in blood pressure and heart rate in all groups. No increase in ETCO 2 was demonstrated following induction of pneumoperitoneum in the 12 and 8 mmHg groups. A statistical significant increase in ETCO 2 occurred only in the 5 mmHg group (39.4 to 41.3 mmHg, p = 0.023).
Background A grading system for postoperative complications is important for quality control and ... more Background A grading system for postoperative complications is important for quality control and comparison among investigations. The objective of the current study was to evaluate complications associated with laparoscopic colorectal surgery according to a standardized grading system, and to examine risk factors associated with different complication grades. Methods Data of all patients who underwent elective laparoscopic colorectal surgery at two medical centers between September 2003 and January 2011 were collected prospectively. Complications were graded retrospectively into five categories based on a previously proposed grading system for colorectal operations. Age, gender, BMI, Charlson comorbidity score, indication for surgery, pathology site, conversion rate, learning curve, operative times, previous abdominal surgery, concurrent surgical procedures performed, and length of hospital stay were evaluated as risk factors and outcome measures for complications. Results A total of 501 patients were included in the study. Of them, 30.5 % suffered at least one complication and 6.5 % more than one. Complications that were mainly medical or surgical site infections requiring minor intervention (grades 1 and 2) occurred in 22.9 % of patients. Surgical complications requiring invasive interference (grades 3 and 4) occurred in 7.4 % of patients and mortality (grade 5) occurred in 0.2 % (1 patient). Length of hospital stay was directly related to complication grade. Average hospital stay was 6.8 ± 3.5, 10.5 ± 5.1, and 20.2 ± 12.3 days for patients with no complications, grade 1-2 complications, and grade 3-4 complications, respectively (p \ 0.01). Minor complications (grades 1-2) were associated with conversion (p \ 0.01), high Charlson score (p = 0.004), and additional surgical procedures (p = 0.04). Major complications (grades 3-4) were associated solely with conversion (p \ 0.01) and rectal pathology (p \ 0.01). Conclusion This study demonstrates the use of a uniform grading system for complications in laparoscopic colorectal surgery. Conversion was found to be associated with all grades of complications. Keywords Complications Á Grading Á Laparoscopic colorectal surgery An accurate and uniform grading system for postoperative complications has great clinical and research importance. It serves as a quality control tool for a single surgeon or medical center, and provides an important comparative tool for investigations and surgical approaches. Dindo et al. [1] proposed a grading system for the complications of all surgical procedures, based on patient outcomes. Mazeh et al. [2] have since introduced a system specifically for surgical complications of colorectal resections, based on 5
Introduction. There are currently no reports in the literature regarding changes in end-tidal car... more Introduction. There are currently no reports in the literature regarding changes in end-tidal carbon dioxide (ETCO 2) when the small bowel is deliberately or inadvertently perforated during laparoscopic surgery. The aim of this study was to assess the influence of small bowel perforation during laparoscopy on ETCO 2 in a rat model. Materials and methods. Two groups of Wistar rats (n ؍ 8/group) were anesthetized, tracheostomized, and mechanically ventilated at a fixed tidal volume and respiratory rate. After a stabilization phase of 30 min, CO 2 pneumoperitoneum was established to 5 mmHg in one group and 12 mmHg in the other group, and maintained for 30 min. A small bowel perforation was then created and pneumoperitoneum was reestablished for another 30 min. Blood pressure, heart rate, peak ventilatory pressure, and ETCO 2 were recorded throughout the experiment. Results. No significant changes in blood pressure throughout the experiment were noted in either group. The ventilatory pressure increased in both groups after the induction of pneumoperitoneum. In the 5 mmHg group, there was a modest increase in ETCO 2 following the induction of pneumoperitoneum (from 39.4 ؎ 1.9 to 41.1 ؎ 1.4, P ؍ 0.014), and a further increase following the small bowel perforation (from 41.1 ؎ 1.4 to 42 ؎ 0.8, P ؍ 0.007). In the 12 mmHg group, there was no change in ETCO 2 after the induction of pneumoperitoneum; however, there was a substantial increase in ETCO 2 following bowel perforation (35.0 ؎ 2.0 to 49.8 ؎ 7.1, P ؍ 0.002). Conclusions. ETCO 2 increases when the small bowel is perforated during CO 2 pneumoperitoneum. This increase seems more substantial under higher pneumoperitoneal pressures. Small bowel injury may enable the diffusion of CO 2 through the bowel mucosa, causing ETCO 2 elevation. Therefore, an abrupt increase in ETCO 2 observed during laparoscopy may indicate small bowel injury.
Background: Entero-atmospheric fistula (EAF) is a devastating rare complication after abdominal s... more Background: Entero-atmospheric fistula (EAF) is a devastating rare complication after abdominal surgery. When parenteral feeding is not feasible, an enteral feeding access must be obtained. A Trans-Fistula Percutaneous Endoscopic Jejunostomy (TF-PEJ) approach is presented. Case presentation: A young male that underwent emergent pancreatoduodenectomy developed three complicated proximal EAF, following multiple laparotomies and an open abdomen approach. Oral feeding was unsuccessful due to considerable fistulae drainage. Liver insufficiency led to total parenteral nutrition (TPN) discontinuation. TF-PEJ was inserted for nutritional support. Conclusion: After the TF-PEJ insertion, the patient recuperated and was discharged home, currently he is awaiting definitive treatment. A TF-PEJ is a creative solution for feeding patients with a proximal fistula.
Background Patient attendance at emergency departments (EDs) during the COVID-19 pandemic outbrea... more Background Patient attendance at emergency departments (EDs) during the COVID-19 pandemic outbreak has decreased dramatically under the "stay at home" and "lockdown" restrictions. By contrast, a notable rise in severity of various surgical conditions was observed, suggesting that the restrictions coupled with fear from medical facilities might negatively impact non-COVID-19 diseases. This study aims to assess the incidence and outcome of complicated appendicitis (CA) cases during that period. Methods A retrospective study comparing the rate and severity of acute appendicitis (AA) cases during the COVID-19 initial outbreak in Israel during March and April of 2020 (P20) to the corresponding period in 2019 (P19) was conducted. Patient data included demographics, pre-ED status, surgical data, and postoperative outcomes. Results Overall, 123 patients were diagnosed with acute appendicitis, 60 patients during P20 were compared to 63 patients in P19. The rate of complicated appendicitis cases was significantly higher during the COVID-19 Lockdown with 43.3% (26 patients) vs. 20.6% (13 patients), respectively (p < 0.01). The average delay in ED presentation between P20 and P19 was 3.4 vs. 2 days (p = 0.03). The length of stay was 2.6 days in P20 vs. 2.3 days in P19 (p = 0.4), and the readmission rate was 12% (7 patients) vs. 4.8% (3 patients), p = 0.17, respectively. Logistic regression demonstrated that a delay in ED presentation was a significant risk factor for complicated appendicitis (OR 1.139, CI 1.011-1.284). Conclusion The effect of the COVID-19 initial outbreak and Lockdown coupled with hesitation to come to medical facilities appears to have discouraged patients with acute appendicitis from presenting to the ED as complaints began, causing a delay in diagnosis and treatment, which might have led to a higher rate of complicated appendicitis cases and a heavier burden on health care systems.
Background: In colorectal cancer, CRP levels on postoperative days 3-4 have a strong negative pre... more Background: In colorectal cancer, CRP levels on postoperative days 3-4 have a strong negative predictive value for an anastomotic leak, with threshold values of ~15 on POD 3 and ~13 on POD 4. In Crohn’s disease, CRP levels are perceived as unreliable in the postoperative period because of the underlying inflammatory process. The aim of this study was to investigate the use of postoperative CRP levels in patients with Crohn’s Disease and set threshold values for this population. Methods: This is a retrospective study of the medical records of adult patients with Crohn’s Disease who underwent bowel anastomoses, at a single, high volume center. The operations were performed by a single colorectal consultant who is an inflammatory bowel disease specialist, between 1/2012 and 12/2017. Results: 92 operations were performed. Mean CRP levels and CRP threshold values were higher in the study’s population compared with studies on colorectal cancer patients. A CRP level of 19.56 mg\dL on posto...
Locally advanced rectal cancer dictates a major surgical undertaking, which includes en bloc rese... more Locally advanced rectal cancer dictates a major surgical undertaking, which includes en bloc resection of the rectum and all involved organs. The aim of this study was to evaluate patient outcome and compare multimodality treatment options after various surgical approaches from one institution for T4 rectal cancer. A retrospective chart review identified 24 patients who were operated on for advanced primary rectal cancer invading adjacent structures (T4) over a 5½-year period. The types of treatment and outcome were analyzed. From these 24 patients, the most frequently involved organ was the bladder (33%). A total of 16 patients underwent chemoradiotherapy. There were 12 complications (50%), the most common being wound infection (33% of complications, 17% overall). Nine patients had nodal disease. Disease-free survival was 54 per cent, and overall survival was 75 per cent. However, disease-free survival in node-negative patients was 67 per cent versus 33 per cent in node-positive in...
Cancer-associated fibroblasts of the stroma play a major role in tumor promoting processes. In th... more Cancer-associated fibroblasts of the stroma play a major role in tumor promoting processes. In this study we evaluated the significance of Phospholipase D (PLD) enzyme activity in promoting human colon cancer malignant potency when interacting with proximal colonic fibroblasts. Human colon cancer cell lines SW480 and HCT116, and colonic fibroblasts CCD-18Co were used as an in vitro model. PLD's activity was measured in resting cancer cells and after culturing with fibroblasts and cancer-associated fibroblasts (CAFs) conditioned medium. The viability and migration level of the cancer cells alone and after co-culturing with fibroblast or CAFs conditioned medium were evaluated, with and without adding a PLD inhibitor. Exposure of colon cancer cells to CAFs conditioned medium significantly increased the level of PLD activity in the cancer cells (p<0.0001). Exposure of colon cancer to resting and activated fibroblast conditioned medium significantly enhanced the number of viable c...
International Journal of Surgery Case Reports, 2017
INTRODUCTION: Postoperative small bowel obstruction due to intussusception is a rare entity but c... more INTRODUCTION: Postoperative small bowel obstruction due to intussusception is a rare entity but can lead to severe morbidity and even mortality. We present a case of this rare complication produced by an unusual cause. CASE REPORT: A 22 year old male, who is a fruitarian, presented to the E.R on day 6 after laparotomy due to obstructing fetobezors that were removed via gastrotomy and enterotomy. In his readmission, he had severe, diffuse abdominal pain, distended abdomen and diffuse peritonitis. Abdominal computed tomography (CT) showed a large amount of fluid in the abdomen, distended small bowel loops, a small amount of free air around the stomach and a suspected ileo-ileal intussusception. The patient underwent emergent laparotomy which revealed an ileo-ileal intussusception with the sutured enterotomy site from the previous operation as the lead point. In addition, a minor dehiscence of the gastrotomy site was identified. A reduction of the intussusception was performed with resection of the enterotomy site and side to side anastomosis. The gastrotomy site was debrided and re-sutured. Recovery was uneventful. CONCLUSION: Postoperative intussusception, although rare, is potentially a dangerous complication, often not involving the site of the primary operation. To our knowledge this is the first report of an intussusception with a sutured enterotomy site as the lead point. Clinicians should be aware of this entity when assessing a patient with abdominal pain and distention after surgery with enterotomy or resection of bowel.
Anastomotic leak after colorectal surgery is a severe complication leading to major postoperative... more Anastomotic leak after colorectal surgery is a severe complication leading to major postoperative morbidity and mortality. Leaks typically present on the 5th to 6th postoperative days; however, early anastomotic dehiscence occurs occasionally. This study evaluated carcinoembryonic antigen (CEA) levels in abdominal drains after colorectal resection to assess its potential as an early marker to predict anastomotic leaks. This prospective study included 105 patients undergoing elective colorectal surgery. Fluids from the patients&amp;amp;#39; abdominal drain system were sampled daily for up to 3 days after surgery and evaluated for CEA levels. Early anastomotic dehiscence occurred in 3 patients (2.8%) and was associated with a significant elevation of CEA in drain fluids (above 1,000 ng/mL). However, in patients who developed late leaks (7 patients, 6.7%) no significant elevation of CEA was observed. Significant elevation of CEA levels in abdominal drains in the early postoperative period may indicate early anastomotic dehiscence.
Background.Clinical data and animal models support an association between postoperative inflammat... more Background.Clinical data and animal models support an association between postoperative inflammatory response and the risk of colorectal cancer recurrence. Our aim was to evaluate postoperative peritoneal inflammation and its impact on cultured colon cancer cells’ migration capacity.Methods.23 patients undergoing elective colorectal resection with uneventful recovery were prospectively enrolled. Patients were operated on for both malignant and benign etiologies. Peritoneal fluids collected at surgery initiation and after surgery were evaluated for their effect on migration potential of human colon cancer cells using anin vitroscratch assay and on TNF-α, IL-1β, IL-6, and IL-10 levels using bead-based fluorokine-linked multianalyte profiling.Results.Postoperative peritoneal fluid from all patients increased the migration capacity of colon cancer cells compared to preoperative levels. This effect was significant during the first two postoperative days and decreased thereafter. The incr...
Weight loss in morbidly obese patients is associated with changes in thyroid function. Studies ha... more Weight loss in morbidly obese patients is associated with changes in thyroid function. Studies have demonstrated equivalent changes following bariatric surgery. Changes in thyroid function were reported following laparoscopic Roux-en-Y gastric bypass (LRYGB), biliopancreatic diversion (BPD), and laparoscopic adjustable gastric banding (LAGB). No data exists on changes in thyroid function following laparoscopic sleeve gastrectomy (LSG). The aim of the current study is to evaluate changes in thyroid function following LSG in patients with normal thyroid function. Data were retrieved from a prospectively collected database of patients who underwent LSG for morbid obesity. Euthyroid patients were evaluated for changes in TSH and free thyroxine (FT4), 6-12 months after surgery. Correlation between changes in thyroid hormone levels, excess weight loss (EWL), and baseline TSH were evaluated. Thirty-eight patients were included in the study. Mean BMI decreased from 42.4 to 32.5 kg/m(2) (P &...
Peritoneal carcinoembryonic antigen (pCEA) levels in the early postoperative period following a c... more Peritoneal carcinoembryonic antigen (pCEA) levels in the early postoperative period following a curative resection of colorectal cancer (CRC) have not been previously studied. Postoperative peritoneal fluids of 36 CRC patients followed by 24 benign colonic disease patients were evaluated for CEA levels and tumor cell presence. Serum CEA levels were also evaluated prior and after surgery. Although high postoperative pCEA levels were observed in some benign patients, more CRC patients exhibited significant elevation of postoperative pCEA (>5 ng/ml) compared to benign patients (50% vs. 23%, P = 0.039). Postoperative median pCEA levels of CRC patients were significantly higher compared to benign patients (5.4 vs. 2 ng/ml, P = 0.011). Specifically, pCEA levels in CRC patients were significantly elevated when measured during the first 24 hr after surgery. Postoperative pCEA levels were associated with colon tumor location compared to rectal location. However, no correlation was found w...
The Israel Medical Association journal : IMAJ, 2011
Major changes in the evaluation and treatment of curable colorectal cancer (CRC) have emerged in ... more Major changes in the evaluation and treatment of curable colorectal cancer (CRC) have emerged in the last two decades. These changes have led to better patient outcome overtime. To evaluate the impact of these changes as reflected in the difference in long-term outcome of a consecutive group of recently laparoscopically operated curable CRC patients and a consecutive group of patients operated 20 years earlier in the same department. Data of the new group were taken from our prospectively collected data of patients who underwent elective laparoscopic surgery for CRC in recent years. Data regarding patients operated on 20 years ago were retrieved from previous prospectively collected data on the long-term survival of CRC patients operated in the same department. The recently operated group comprised 203 patients and the previous group 199 patients. Perioperative mortality was 0.5% in the new group versus 1.5% in the old group (not significant). There were more early-stage and more pr...
The Israel Medical Association journal : IMAJ, 2011
The effect of anti-platelet drugs on surgical blood loss and perioperative complications has not ... more The effect of anti-platelet drugs on surgical blood loss and perioperative complications has not been studied in depth and the management of surgical patients taking anti-platelet medications is controversial. To assess the effect of anti-platelet therapy on perioperative blood loss in patients undergoing appendectomy either laparoscopically or via open surgery. We reviewed the files of all patients 40 years old who underwent open or laparoscopic appendectomies from 2007 to 2010. Excluded were patients with short hospitalization and no follow-up of hemoglobin level, patients on warfarin treatment and patients who underwent additional procedures. Estimation of blood loss was based on decrease in hemoglobin level from admission to discharge. Risk factors for blood loss, such as anti-platelet therapy, age, gender, surgical approach, surgical time, surgical findings and complications, were analyzed. The final cohort included 179 patients (mean age 61 +/- 14 years, range 40-93) of whom 6...
The Israel Medical Association journal : IMAJ, 2011
Esophageal perforations and postoperative esophageal leaks are associated with substantial morbid... more Esophageal perforations and postoperative esophageal leaks are associated with substantial morbidity and mortality and pose a difficult therapeutic challenge. Toevaluate the outcome ofremovableself-expanding metallic stents (SEMS) as a treatment for postoperative leaks and perforations of the esophagus and stomach. We conducted a retrospective study of all patients in one medical center who underwent temporary insertion of a covered plastic stent for postoperative leaks and perforations of the esophagus and stomach from June 2009 to February 2010. Data were retrieved from hospital and outpatient clinical data charts. Data included indication for insertion, post-insertion outcome including stent complications, and follow-up after stent removal. The indications for stent insertion were postoperative leak in four patients and postoperative esophagopleural fistula in one patient. Three of the patients had a leak at the gastroesophageal junction following laparoscopic sleeve gastrectomy....
Background: Traditional esophagectomy may be associated with mortality, considerable morbidity, a... more Background: Traditional esophagectomy may be associated with mortality, considerable morbidity, and lengthy recovery. It is often performed in cancer patients who are typically older, have associated comorbidities, and are often malnourished, all factors that increase surgical risk. Minimally invasive esophagectomy has the potential advantages of being a less traumatic procedure with an easier postoperative recovery and fewer wound and pulmonary complications. Methods: A retrospective analysis of patients who underwent laparoscopic transhiatal esophagectomy was performed. Assessed parameters included patient demographics and operative data, pathology results, and long-term follow-up of at least 12 months. Results: Twenty-two patients underwent laparoscopic transhiatal esophagectomy; 19 had esophageal cancer. Two patients were operated on for Barrett esophagus, and 1 patient had achalasia. The majority of patients were men (82%), and the mean age was 59 years (range 15 to 74 years); 1 patient (4.5%) was converted to open surgery. The average operative time was 380 minutes (range 285 to 525 minutes), and the average blood loss was 220 mL; only 3 patients required transfusion. The median hospital stay was 8 days (range 5 to 46 days). Postoperative mortality occurred in 1 patient (4.5%), and postoperative complications developed in 6 patients (27.2%). In the 19 cancer patients, the average number of harvested nodes was 14.3 (range 10 to 19). The average follow-up was 30 months (range 12 to 48 months). The overall survival for cancer patients was 61% (11 of 19), and disease-free survival was 39% (7/19). Conclusions: Esophagectomy is a major surgery with considerable morbidity and potential mortality. Minimally invasive esophagectomy is a feasible approach that can be safely performed by surgeons with extensive experience in that field. Advantages include less intraoperative blood loss, a smaller incision, and a potentially faster postoperative recovery. In cancer patients, immediate oncologic goals of adequate margins and lymph node dissection can be achieved, and long-term outcome appears to be similar to that found with open approaches.
Introduction Many studies have reported on the effects of pneumoperitoneum in a rat model, using ... more Introduction Many studies have reported on the effects of pneumoperitoneum in a rat model, using a wide range of intra-abdominal pressures. The correlation between pneumoperitoneal pressures in rodents to pressures in humans has not been established. This study evaluates changes in various physiological parameters in different pneumoperitoneum pressures in the rat model with a comparison to known data in humans. Materials and methods Three groups of eight Wistar rats each were anesthetized, tracheostomized, and mechanically ventilated with fixed tidal volume and respiratory rate. After a stabilization phase, CO 2 pneumoperitoneum was established to 12, 8, and 5 mmHg in the different groups. Changes in blood pressure, heart rate, peak ventilatory pressure, and end-tidal CO 2 (ETCO 2) were recorded throughout the experiment. Results There were no significant changes in blood pressure and heart rate in all groups. No increase in ETCO 2 was demonstrated following induction of pneumoperitoneum in the 12 and 8 mmHg groups. A statistical significant increase in ETCO 2 occurred only in the 5 mmHg group (39.4 to 41.3 mmHg, p = 0.023).
Background A grading system for postoperative complications is important for quality control and ... more Background A grading system for postoperative complications is important for quality control and comparison among investigations. The objective of the current study was to evaluate complications associated with laparoscopic colorectal surgery according to a standardized grading system, and to examine risk factors associated with different complication grades. Methods Data of all patients who underwent elective laparoscopic colorectal surgery at two medical centers between September 2003 and January 2011 were collected prospectively. Complications were graded retrospectively into five categories based on a previously proposed grading system for colorectal operations. Age, gender, BMI, Charlson comorbidity score, indication for surgery, pathology site, conversion rate, learning curve, operative times, previous abdominal surgery, concurrent surgical procedures performed, and length of hospital stay were evaluated as risk factors and outcome measures for complications. Results A total of 501 patients were included in the study. Of them, 30.5 % suffered at least one complication and 6.5 % more than one. Complications that were mainly medical or surgical site infections requiring minor intervention (grades 1 and 2) occurred in 22.9 % of patients. Surgical complications requiring invasive interference (grades 3 and 4) occurred in 7.4 % of patients and mortality (grade 5) occurred in 0.2 % (1 patient). Length of hospital stay was directly related to complication grade. Average hospital stay was 6.8 ± 3.5, 10.5 ± 5.1, and 20.2 ± 12.3 days for patients with no complications, grade 1-2 complications, and grade 3-4 complications, respectively (p \ 0.01). Minor complications (grades 1-2) were associated with conversion (p \ 0.01), high Charlson score (p = 0.004), and additional surgical procedures (p = 0.04). Major complications (grades 3-4) were associated solely with conversion (p \ 0.01) and rectal pathology (p \ 0.01). Conclusion This study demonstrates the use of a uniform grading system for complications in laparoscopic colorectal surgery. Conversion was found to be associated with all grades of complications. Keywords Complications Á Grading Á Laparoscopic colorectal surgery An accurate and uniform grading system for postoperative complications has great clinical and research importance. It serves as a quality control tool for a single surgeon or medical center, and provides an important comparative tool for investigations and surgical approaches. Dindo et al. [1] proposed a grading system for the complications of all surgical procedures, based on patient outcomes. Mazeh et al. [2] have since introduced a system specifically for surgical complications of colorectal resections, based on 5
Introduction. There are currently no reports in the literature regarding changes in end-tidal car... more Introduction. There are currently no reports in the literature regarding changes in end-tidal carbon dioxide (ETCO 2) when the small bowel is deliberately or inadvertently perforated during laparoscopic surgery. The aim of this study was to assess the influence of small bowel perforation during laparoscopy on ETCO 2 in a rat model. Materials and methods. Two groups of Wistar rats (n ؍ 8/group) were anesthetized, tracheostomized, and mechanically ventilated at a fixed tidal volume and respiratory rate. After a stabilization phase of 30 min, CO 2 pneumoperitoneum was established to 5 mmHg in one group and 12 mmHg in the other group, and maintained for 30 min. A small bowel perforation was then created and pneumoperitoneum was reestablished for another 30 min. Blood pressure, heart rate, peak ventilatory pressure, and ETCO 2 were recorded throughout the experiment. Results. No significant changes in blood pressure throughout the experiment were noted in either group. The ventilatory pressure increased in both groups after the induction of pneumoperitoneum. In the 5 mmHg group, there was a modest increase in ETCO 2 following the induction of pneumoperitoneum (from 39.4 ؎ 1.9 to 41.1 ؎ 1.4, P ؍ 0.014), and a further increase following the small bowel perforation (from 41.1 ؎ 1.4 to 42 ؎ 0.8, P ؍ 0.007). In the 12 mmHg group, there was no change in ETCO 2 after the induction of pneumoperitoneum; however, there was a substantial increase in ETCO 2 following bowel perforation (35.0 ؎ 2.0 to 49.8 ؎ 7.1, P ؍ 0.002). Conclusions. ETCO 2 increases when the small bowel is perforated during CO 2 pneumoperitoneum. This increase seems more substantial under higher pneumoperitoneal pressures. Small bowel injury may enable the diffusion of CO 2 through the bowel mucosa, causing ETCO 2 elevation. Therefore, an abrupt increase in ETCO 2 observed during laparoscopy may indicate small bowel injury.
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Papers by Shmuel Avital