Publications by authors named "Hanoch Kashtan"

58 Publications

Proteomic analysis to identify markers for response to neoadjuvant treatment in esophageal and gastroesophageal cancer.

Cancer Rep (Hoboken) 2021 Aug 5:e1489. Epub 2021 Aug 5.

Department of Surgery, Rabin Medical Center, Petach Tikva, Israel.

Background: Esophageal cancer represents a global challenge. Despite significant evolution of treatment protocols in the past decade, recurrence rates are still high and survival rates are poor. Current treatment paradigm for localized gastroesophageal junction (GEJ) carcinoma remains to be further elucidated as for the role of neoadjuvant chemoradiation versus perioperative chemotherapy.

Aim: To identify biomarkers for response to chemoradiation in esophageal and gastroesophageal cancer, we performed an in-depth proteomic analysis of esophageal and gastroesophageal tumors, to describe differences in pathway activation between patients with favorable and poor prognosis following neoadjuvant chemoradiation.

Methods: Patients with locally advanced esophageal and gastroesophageal cancer following neoadjuvant chemoradiation were included in the cohort. The study cohort was dichotomized into two groups of patients, named "favorable prognosis" and "poor prognosis" according to the postoperative disease-free interval. We performed a mass spectrometry analysis of proteins extracted from the malignant regions of surgical specimens and analyzed data from electronic medical records. Clinical data was correlated with differences in protein expression between patient with a favorable and poor prognosis using validated gene expression pathways.

Results: The study included 35 patients with adenocarcinoma. All patients in this cohort had esophageal adenocarcinoma. Patients median age was 62 years. Twenty-five (71.3%) patients underwent neoadjuvant chemoradiation, and 28.7% underwent neoadjuvant chemotherapy only. A proteomic analysis of our cohort identified 2885 proteins. Enrichment levels of 98 of these proteins differed significantly between favorable and poor prognosis cohorts in patients who underwent neoadjuvant chemoradiation (p < .05) but not in patients who underwent neoadjuvant chemotherapy. The favorable prognosis patients group analysis exhibited differential enrichment of 87 proteins related to cellular respiration and oxidative phosphorylation pathways as well as proteins of the RAS oncogene family.

Conclusion: In this study we identified differential enrichment of pathways related to oxidative phosphorylation and RAS oncogene pathway in esophageal cancer patients with a favorable response to chemoradiation. Following further validation, our findings may portray potential surrogate signature of biomarkers based upon these pathways.
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http://dx.doi.org/10.1002/cnr2.1489DOI Listing
August 2021

High Rates of Incisional Hernia After Laparoscopic Right Colectomy With Midline Extraction Site.

Surg Laparosc Endosc Percutan Tech 2021 Jul 28. Epub 2021 Jul 28.

Department of Surgery Department of Imaging, Rabin Medical Center, Beilinson Hospital, Petach Tikva Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Laparoscopic surgery aims at reducing wound complications and improving cosmetics, among other advantages. High rates of postoperative ventral hernia (POVH) are observed after laparoscopic-assisted colectomies.

Materials And Methods: In a 2011 to 2016 retrospective study of all patients at Rabin Medical Center, we examined POVH prevalence after right hemicolectomy for neoplasia and correlation to specimen extraction site. We also compared laparoscopic-assisted colectomy to hand-assisted laparoscopic colectomy. Included were patients who had postoperative abdominal computed tomography or magnetic resonance imaging scan as part of their routine oncological follow-up to 6 months postsurgery. Patients were excluded for conversion to laparotomy, and prior abdominal surgeries after right colectomy and before follow-up computed tomography/magnetic resonance imaging scan. Demographic and surgical data were collected from patient electronic records, and scans reviewed for POVH by a designated radiologist.

Results: Of 370 patients, 138 (mean age 70.09 y, 58 males) were included: 54 (39.1%) were diagnosed with POVH, 42/72 (58.3%) at midline extraction site, and 12/66 (18.8%) at off-midline extraction sites (P<0.0001). Surgical site infections and patients positive for tumor metastasis were associated with higher POVH rates. Most (74%) POVHs were identified within 18 months postsurgery (P<0.0001). Body mass index, age, sex, diabetes mellitus, smoking, tumor size, lymph nodes positive for metastasis, and hand-assisted laparoscopic colectomy were not associated with POVH prevalence.

Conclusion: High rates of radiologically diagnosed POVH were found after laparoscopic-assisted colectomy, with association to midline extraction site, surgical site infections, and positive tumor distant metastasis.
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http://dx.doi.org/10.1097/SLE.0000000000000977DOI Listing
July 2021

Paraesophageal hernia: to fundoplicate or not?

Ann Transl Med 2021 May;9(10):902

Department of General Surgery, Rabin Medical Center, Campus Beilinson, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Petach-Tikva, Israel.

The need for an antireflux procedure during repair of a paraesophageal hernia (PEH) has been the subject of a long-standing controversy. With most centers now performing routine fundoplication during PEH repair, high-quality data on whether crural repair alone or using a mesh may provide adequate anti-reflux effect is still scarce. We sought to answer to the question: "Is fundoplication routinely needed during PEH repair?". Our endpoints were (I) rates of postoperative gastroesophageal reflux disease (GERD) (either symptomatic or objectively assessed), (II) rates of recurrence, and (III) rates of postoperative dysphagia. We searched the MEDLINE, Cochrane, PubMed, and Embase databases for papers published between 1995 and 2019, selecting comparative cohort studies and only including papers reporting the rationale for performing or not performing fundoplication. Overall, nine papers were included for review. While four of the included studies recommended selective or no fundoplication, most of these data come from earlier retrospective studies. Higher-quality data from recent prospective studies including two randomized controlled trials recommended routine fundoplication, mostly due to a significantly lower incidence of postoperative GERD. However, only a relatively short follow-up of 12 months was presented, which we recognize as an important limitation. Fundoplication did not seem to result in reduced recurrence rates when compared to primary repair alone.
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http://dx.doi.org/10.21037/atm.2020.03.106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8184421PMC
May 2021

Neutrophil-to-Lymphocyte Ratio Predicts Recurrence Pattern in Patients with Resectable Colorectal Liver Metastases.

Ann Surg Oncol 2021 Aug 22;28(8):4320-4329. Epub 2021 Apr 22.

Department of Surgery, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.

Background: Studies have suggested that neutrophil-to-lymphocyte ratio (NLR) has value as a predictor of long-term outcomes in various cancer types. Its prognostic potential in patients with CRLM has not been thoroughly investigated. This original, retrospective study assessed the relationship between the preoperative NLR, survival outcomes, and recurrence patterns in patients after colorectal liver metastasis resection (CRLM).

Methods: The prospectively maintained database of a tertiary medical center was queried for all patients who underwent CRLM resection between 2005 and 2017. Patients were divided into two groups: NLR <3 (normal) or >3 (high). Recurrence risk was analysed using Fine and Gray correction for competing risk method and cause specific analyses.

Results: The cohort included 231 patients of whom 53 (23%) had a high neutrophil-to-lymphocyte ratio. At presentation, 35% had synchronous disease and 48% had a solitary metastasis; median tumor size was 2 cm. Patients with a high NLR had a significantly higher rate of simultaneous colorectal resection (P = 0.01). A high NLR was independently associated with worse OS (P = 0.02), worse DFS (P = 0.03), and higher risk of recurrence (P = 0.048), specifically recurrence with an extrahepatic pattern (P = 0.03).

Conclusions: A high preoperative NLR was independently associated with poorer survival outcomes and extrahepatic recurrence pattern. The NLR appears to have prognostic importance in CRLM and may serve as a surrogate marker of aggressive systemic disease after resection. These findings warrant external validation, preferably in a prospective design.
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http://dx.doi.org/10.1245/s10434-021-10000-6DOI Listing
August 2021

Signet Ring Cell Features are Associated with Poor Response to Neoadjuvant Treatment and Dismal Survival in Patients with High-Grade Esophageal Adenocarcinoma.

Ann Surg Oncol 2021 Sep 11;28(9):4929-4940. Epub 2021 Mar 11.

Department of Surgery, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel.

Background: While the prognosis of patients with locoregional esophageal adenocarcinoma (EAC) has improved in the neoadjuvant treatment (NAT) era, high-grade histology (G3) is still associated with a limited treatment response. We sought to investigate oncologic outcomes in patients after esophagectomy for G3 EAC and to identify predictors of poor survival among these patients.

Methods: Patients with EAC who underwent resection with curative intent in 2011-2018 were divided by histologic grade (G3, G1/2) and compared for overall survival (OS). Cox regression was performed to analyze the response to NAT and the predictive role of signet ring cell (SRC) features.

Results: The cohort included 163 patients, 94 (57.7%) with G3 histology. NAT was administered to 69 (73.4%) patients. Following resection, OS in the G3 EAC group was 30 months (95% confidence interval [CI] 23.9-36.1). On univariate analysis, G3 disease (p = 0.050) and SRC features (p = 0.019) predicted low OS. Median survival in the G3 EAC group was worse in patients with SRC histology (18 months, 95% CI 8.6-27.4) than those without (30 months, 95% CI 23.8-36.1; p = 0.041). No patients with SRC histology were alive at 5 years of follow-up. Among all patients administered NAT, 88.2% of those with SRC showed minimal or no pathologic response and only 27.8% were downstaged.

Conclusions: High-grade histology was found in most patients with EAC and predicted poor survival and treatment response. SRC features in patients with G3 disease were associated with lower OS. The benefit of NAT for G3 EAC in patients with SRC histology appears limited.
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http://dx.doi.org/10.1245/s10434-021-09644-1DOI Listing
September 2021

ASO Author Reflections: High-Grade Status and Signet Ring Cell Features in Esophageal Adenocarcinoma.

Ann Surg Oncol 2021 Sep 25;28(9):4941-4942. Epub 2021 Feb 25.

Department of General Surgery, Rabin Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

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http://dx.doi.org/10.1245/s10434-020-09579-zDOI Listing
September 2021

[POSTGRADUATE MEDICAL EDUCATION DURING COVID-19 PANDEMIC IN ISRAEL].

Harefuah 2020 Dec;159(12):856-860

The Scientific Council of IMA.

Background: The Covid-19 pandemic has posed significant challenges to many aspects of life, including work processes to which we have become accustomed. Health systems world-wide have been affected in numerous ways and face epic and unprecedented challenges. Medical education, both in Israel and around the world, has been deeply impacted. It is no surprise that the institutions responsible for medical education, as well as many other institutions, have had to deal with uncertainty and unrest. In this article, we review the processes adopted by the Scientific Council of the Israel Medical Association, the body responsible for postgraduate medical training in the various medical specialties. The article reviews the actions taken by the Council during the first few months of the pandemic, March-July 2020, in order to maintain the quality of training.
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December 2020

[RESIDENCY EXAMINATIONS IN THE COURSE OF THE COVID-19 CRISIS: THE EFFORTS OF THE ISRAELI SCIENTIFIC COUNCIL TO EXECUTE THE FINAL BOARD ORAL EXAMINATIONS DURING A LOCAL AND A WORLDWIDE PANDEMIC].

Harefuah 2020 Dec;159(12):851-855

The Scientific Council of IMA.

Introduction: The Israeli Scientific Council is responsible for the physician's training process and the residency exams. These are performed in two phases: Stage A (written examination) and Stage B (the final Board oral examination). The COVID-19 pandemic started in Israel a few weeks before the scheduled spring 2020 Stage B exams and had a major impact, not only on the health and economic systems in Israel, but also on the residency exams.

Aims: To describe the efforts of the Israeli Scientific Council to execute the spring 2020 Stage B exams during the COVID-19 pandemic in comparison to the worldwide data, and to deduce the appropriate management during potential future crises.

Methods: We present a description of the activity of the Israeli Scientific Council since the start of the COVID-19 pandemic according to documents and other sources, An internet search was conducted on the destiny of residency examinations throughout the world, and a comparison between them.

Results: Due to rapid worsening in the restrictions enforced in Israel, the spring 2020 oral board exams were cancelled. However, a decision was made to execute them in the summer. This new schedule dictated a delay in the schedule of other residency examinations and forced condensation of 5 periods into 10 months instead of 14. The examination team prepared the new summer exams period under the assumption that heavy restrictions will still be implemented. Indeed, COVID-19 was still around and the restrictions were still enforced. Despite that, all oral Board examinations were perfectly executed. This contrasts with the rest of the world, in which most residency exams were cancelled, even without a solution or an alternative date.

Conclusions: Recruitment of all involved and preparation for the worst-case scenario enabled the perfect execution of the previously cancelled exams, and will enable the execution of future residency exams under conditions of potential health or war crises.

Discussion: To the best of our knowledge, the Israeli Scientific Council is the only communal body in the world which organized an alternative period for the cancelled oral exams, only 4 months after the cancelled dates. Due to an enormous effort and rigorous preparations, Israel is also the only place in which oral exams were successfully executed, physically, under an active disease and very heavy restrictions.
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December 2020

[EVALUATION OF THE ELDERLY PATIENT WITH CANCER].

Harefuah 2020 Sep;159(9):678-682

Department of Geriatrics, Rabin Medical Center, campus Beilinson, Sackler Faculty of Medicine, Tel Aviv University.

Introduction: In recent years, there has been a significant increase in the number of adult patients with malignant diseases. These patients are a major therapeutic challenge due to a high incidence of comorbidities, lower functional status and often a diagnosis of the disease at a relatively advanced stage. The preferred approach to the treatment of cancer is a multidisciplinary approach. In the last decade, we have witnessed the integration of geriatricians as part of the multidisciplinary team in order to better assess patients' ability to withstand oncological or surgical treatment and, if necessary, to prepare them better for these treatments. In this article we review the use of various geriatric tools, such as generalized geriatric assessment, fragility and sarcopenia, and their effect on the decision-making process of the treating physicians and on the outcomes of the various treatments, including the outcomes of the operations. We show that comprehensive geriatric assessment is the basis for the evaluation of the adult oncology patients, and proper preparation for treatment in order to improve the outcomes of the treatment and reduce its complications. The rapid growth rate of the elderly population in Israel, together with the continuous development of oncology and cancer treatments, indicate the need to allocate resources and efforts to treat this unique population. We recommend an integration of geriatricians in the multidisciplinary team that treats this population.
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September 2020

Some Nursing Screening Tools Can Be Used to Assess High-Risk Older Adults Who Undergo Colorectal Surgery for Cancer.

Clin Interv Aging 2020 25;15:1505-1511. Epub 2020 Aug 25.

The Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Aim: Life expectancy and incidence of cancer among older adults are increasing. The aim of this study was to assess whether routinely used nursing screening tools can predict surgical outcomes in older adults with colorectal cancer.

Methods: Data of patients who underwent elective colorectal cancer surgery at Rabin Medical Center during the years 2014-2016 were collected retrospectively. Patients were divided into study group (age 80-89 y), and control group (age 60-69 y) for comparing surgical outcomes and six-month mortality. In the study group, screening tool scores were evaluated as potential predictors of surgical outcomes. These included Malnutrition Universal Screening Tool (MUST), Admission Norton Scale Scores (ANSS), Morse Fall Scale (MFS), and Charlson Co-morbidity Index (CCI).

Results: The study group consisted of 77 patients, and the control group consisted of 129 patients. Postoperative mortality and morbidity were similar in both groups. Nursing screening tools did not predict immediate postoperative outcomes in the study group. MUST and CCI were predictors for six-month mortality. CCI score was 9.43±2.44 in those who died within six months from surgery compared to 7.07 ±1.61 in those who were alive after six months (p<0.05). Post-operative complications were not associated with increased 30-day mortality. Advanced grade complications were associated with an increased six-month mortality (RR=1.37, 95% CI 0.95-1.98, p=0.013).

Conclusion: Different screening tools for high-risk older adults who are candidates for surgery have been developed, with the caveat of necessitating skilled physicians and resources such as time. Routinely used nursing screening tools may be helpful in better patient selection and informed decision making. These tools, specifically MUST and CCI who were found to predict six-month survival, can be used to additionally identify high-risk patients by the nursing staff and promote further evaluation. This can be a valuable tool in multidisciplinary and patient-centered care.
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http://dx.doi.org/10.2147/CIA.S258992DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458272PMC
December 2020

Abdominal Surgery in Patients with a Ventricular Assist Device: A Single Center Experience in Israel.

Isr Med Assoc J 2020 Jun;22(6):369-373

Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel.

Background: Left ventricular assist devices (LVADs) are used more commonly in patients with advanced-stage heart failure. Some of these patients may require elective or urgent abdominal surgical procedures.

Objectives: To determine the outcomes of the management of LVAD-supported patients who underwent elective and urgent abdominal surgical procedures in our institution.

Methods: A retrospective review was conducted on 93 patients who underwent LVAD implantation between August 2008 and January 2017. All abdominal surgeries in these patients were studied, and their impact on postoperative morbidity and mortality Ten patients underwent abdominal surgical procedures. Of these procedures, five were emergent and five were elective. The elective cases included one bariatric surgery for morbid obesity, one hiatal hernia repair, two cholecystectomies, and one small bowel resection for a carcinoid tumor. The emergency cases included suspected ischemic colitis, right colectomy for bleeding adenocarcinoma, laparotomy due to intraabdominal bleeding, open cholecystectomy for gangrenous cholecystitis, and laparotomy for sternal and abdominal wall infection. All patients undergoing elective procedures survived. Of the five patients who underwent emergency surgery, three died (60%, P = 0.16) and one presented with major morbidity. One of the two survivors required reintervention. In total, 12 interventions were performed on this group of patientswas evaluated.

Results: Ten patients underwent abdominal surgical procedures. Of these procedures, five were emergent and five were elective. The elective cases included one bariatric surgery for morbid obesity, one hiatal hernia repair, two cholecystectomies, and one small bowel resection for a carcinoid tumor. The emergency cases included suspected ischemic colitis, right colectomy for bleeding adenocarcinoma, laparotomy due to intraabdominal bleeding, open cholecystectomy for gangrenous cholecystitis, and laparotomy for sternal and abdominal wall infection. All patients undergoing elective procedures survived. Of the five patients who underwent emergency surgery, three died (60%, P = 0.16) and one presented with major morbidity. One of the two survivors required reintervention. In total, 12 interventions were performed on this group of patients.

Conclusions: It is safe to perform elective abdominal procedures for LVAD-supported patients. The prognosis of these patients undergoing emergency surgery is poor and has high mortality and morbidity rates.
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June 2020

Young-onset gastric cancer and Epstein-Barr Virus (EBV) - a major player in the pathogenesis?

BMC Cancer 2020 Jan 14;20(1):34. Epub 2020 Jan 14.

Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Ze'ev Jabotinsky Rd 39, 4941492, Petah Tikva, Israel.

Objective: Gastric cancer (GC) is a leading cause of cancer death, occurs predominantly in older age, with increasing incidence in young patients. The Cancer Genome Atlas indicates four subtypes for GC among which Epstein-Barr virus (EBV) subtype is estimated at 8.7%. We aim to determine the prevalence of EBV subtype in young GC patients (≤45 years) compared with an average-onset cohort (≥55 years) and characterize the clinicopathologic pattern of young-onset GC.

Methods: Gastric cancer samples of patients of both cohorts were screened for EBV by qPCR. Additional staining was done for Human epidermal growth factor receptor 2 (HER2), microsatellite instability (MSI) status and Programmed death-ligand 1 (PD-L1). Demographics and clinical data were retrieved from the medical records.

Results: Thirty-nine young-onset and 35 average-onset GC patients were reviewed. There was no apparent difference in tumor location, family history, histology and HER2 status between the cohorts. More young-onset patients were diagnosed with metastatic disease (27% vs 9%, p = 0.0498). EBV was significantly more prevalent in the young-onset cohort (33% vs 11%, p = 0.025). 15/17 EBV positive patients were under the median age of diagnosis for GC in the US (68 years). MSI-H was found only in the average-onset cohort [0% vs 27%, p = 0.001). PD-L1 positivity was higher in the young-onset cohort (31% vs 3%, p = 0.002).

Conclusion: Our study indicates that EBV subtype is more prevalent in young-onset GC and may play a key role in the pathogenesis. Higher rate of PD-L1 positivity in young-onset GC could change treatment strategies. We are currently evaluating these findings in a prospective trial.
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http://dx.doi.org/10.1186/s12885-020-6517-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6961297PMC
January 2020

Isolated Traumatic Brain Injury in the Very Old.

Isr Med Assoc J 2019 Dec;21(12):779-784

Department of Surgery, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel.

Background: Older age is an independent predictor of worse outcome from traumatic brain injury (TBI). No clear guidelines exist for the management of TBI in elderly patients.

Objectives: To describe the outcomes of elderly patients presenting with TBI and intracranial bleeding (ICB), comparing a very elderly population (≥ 80 years of age) to a younger one (70-79).

Methods: Retrospective analysis of the outcomes of elderly patients presenting with TBI with ICB admitted to a level I trauma center.

Results: The authors analyzed 100 consecutive patients aged 70-79 and 100 patients aged 80 and older. In-hospital mortality rates were 9% and 21% for groups 70-79 and ≥ 80 years old, respectively (P = 0.017). Patients 70-79 years old showed a 12-month survival rate of 73% and a median survival of 47 months. In patients ≥ 80 years old, 12-month survival was 63% and median survival was 27 months (P = NS). In patients presenting with a Glasgow Coma Scale score of ≥ 8, the in-hospital mortality rates were 41% (n=5/12) and 100% (n=8/8). Among patients ≥ 80 years old undergoing emergent surgical decompression, in-hospital mortality was 66% (n=12/18). Survivors presented with a severe drop in their functional score. Survival was dismal in patients ≥ 80 years old who were treated conservatively despite recommended operative guidelines.

Conclusions: There is a lack of reliable means to evaluate the outcome in patients with poor functional status at baseline. The negative prognostic impact of severe TBI is profound, regardless of treatment choices.
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December 2019

[POSTGRADUATE MEDICAL EDUCATION ACCREDITATION IN ISRAEL].

Harefuah 2019 Oct;158(10):659-663

The Scientific Council of the Israeli Medical Association.

Introduction: Accreditation of Post-Graduate Medical Education permits medical institutions to train residents, allowing them to achieve specialist certification. An accreditation system usually employs several tools such as site-visits, information gathering and occasionally self-evaluation, to determine adherence to pre-defined standards. The Scientific Council of the Israeli Medical Association is entrusted by law on this accreditation system in Israel. In our article, we briefly review the Post-Graduate Medical Education accreditation system in Israel and a number of pivotal challenges faced by the Scientific Council in this field in the 21st century. These challenges include the adaptation to different medical settings such as community based clinics and medical arrays, the adaptation of tools used for accreditation, new methods for up to date information gathering and updated structure of site-visit teams. A significant future challenge will be adapting the accreditation system to the new Competency Based Medical Education model of residency promoted in Israel by the Scientific Council.
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October 2019

The addition of cetuximab to preoperative chemoradiotherapy for locally advanced esophageal squamous cell carcinoma is associated with high rate of long term survival: Mature results from a prospective phase Ib/II trial.

Radiother Oncol 2019 05 4;134:74-80. Epub 2019 Feb 4.

Institute of Oncology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach Tiqva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Tel-Aviv, Israel.

Aim: This phase IB/II study evaluated the safety and efficacy of the addition of cetuximab to standard preoperative chemoradiotherapy (CRT) in locally advanced esophageal cancer (LAEC).

Methods: Patients (pts) with resectable LAEC (TNM, TNM or TNM received an induction cycle of cisplatin 100 mg/m, day 1, and 5-fluorouracil (5-FU) 1000 mg/m/day, days 1-5, followed 4 weeks later by radiotherapy, 50.4 Gy, given with 2 cycles of cisplatin 75 mg/m and escalating doses of 5-FU, days 1-4 and 29-32. Pts received 10 weekly infusions of cetuximab, 250 mg/m, with a loading dose, 400 mg/m. Surgery was planned 6-8 weeks after CRT.

Results: 64 pts were treated and 60 completed CRT. Median age was 65 years and 66% were males. Adenocarcinoma/squamous ratio was 61%/39%. Tumors were advanced: 95% T and 67% N. Grade ≥3 toxicities occurred in 72%, with two (3%) toxic deaths. The 5-FU maximal tolerated dose (MTD) was 1000 mg/m/day. Clinical complete response rate was 33%. Of the 55 operated pts, R0 resection was achieved in 51 (93%) and pathological complete response (pCR) in 18 (33%), with 8 (14%) postoperative deaths. The 5-year survival rate for all pts was 38%. Pts with squamous histology had higher pCR (55% vs 20%, p = 0.015), local control (96% vs. 74%, p < 0.001) and 5-year survival (58% vs 25%, p = 0.011) rates.

Conclusions: This study suggests that the addition of cetuximab to standard preoperative CRT is feasible. R0, pCR and local control rates are encouraging. Pts with squamous cell tumors benefited more from the addition of cetuximab.
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http://dx.doi.org/10.1016/j.radonc.2019.01.013DOI Listing
May 2019

Baseline 18F-FDG PET/CT as predictor of the pathological response to neoadjuvant therapy in esophageal cancer: A retrospective study.

Medicine (Baltimore) 2018 Dec;97(49):e13412

Department of Nuclear Medicine, Rabin Medical Center, Beilinson Hospital.

The type of pathological response to neoadjuvant chemoradiation in patients with locally advanced esophageal cancer predicts overall survival (OS).We aimed to assess early 18F-FDG positron emission tomography/computed tomography parameters in predicting the pathological response to neoadjuvant treatment.The cohort included consecutive patients with locally advanced esophageal cancer who underwent baseline 18F-FDG positron emission tomography/computed tomography between September 2006 and February 2015. Positron emission tomography variables of maximum and average standardized uptake values (SUVmax, SUVaverage), metabolic tumor volume (MTV), and total lesion glycolysis were recorded in addition to computed tomography volume. MTV was calculated using cut-off values of 42%, 50% and 60% (MTV 0.42, 0.5, and 0.6) of the tumoral SUVmax. Receiver operating characteristic (ROC) analysis was used to determine sensitivity and specificity.Sixty-one patients (44 male, 17 female) fulfilled the inclusion criteria. Only MTV values of 13.6 mL (MTV 0.42) and 7.4 mL (MTV 0.5) remained significant on ROC analysis, with an area under the curve of 0.690 (confidence interval 0.557-0.823, p = .02] and 0.664 (confidence interval 0.527-0.802, P = .048), respectively in differentiating patients with a complete (n = 44) or incomplete (n = 17) pathological response.MTV at presentation is associated with the pathological response to neoadjuvant chemoradiation in patients with locally advanced esophageal cancer.
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http://dx.doi.org/10.1097/MD.0000000000013412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6310504PMC
December 2018

Early PET-CT in patients with pathological stage III colon cancer may improve their outcome: Results from a large retrospective study.

Cancer Med 2018 11 22;7(11):5470-5477. Epub 2018 Oct 22.

Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach Tiqva, Israel.

Background: Current staging of pathological stage III colon cancer (CC) is suboptimal; many patients recur despite unremarkable preoperative staging. We previously reported that early postoperative PET-CT can alter the stage and management of up to 15% of patients with high-risk stage III CC. This study aimed to determine the role of the test in the general stage III CC population.

Methods: A retrospective study of all consecutive patients with stage III CC who underwent early postoperative PET-CT between 2005 and 2017.

Results: A total of 342 patients, 166 (48.5%) males, median age 66 years (range, 29-90), were included. Pathological stage was IIIA, IIIB, and IIIC in 18 (5.3%), 257 (75.1%), and 67 (19.6%) patients, respectively. Median number of positive lymph nodes was 2 (range, 0-32). PET-CT results modified the management of 46 patients (13.4%): 37 (10.8%) with overt metastatic disease and 9 (2.6%) with a second primary. The 5-year disease-free survival for true stage III patients was 81%. The median overall survival for the entire cohort and for true stage III patients was not reached and was 57.2 months for true stage IV. Of the 37 patients found to be metastatic, 14 (37.8%) underwent curative treatments and 9/14 (64.3%) remain disease-free, with a median follow-up of 83.8 months. Predictive factors for upstaging following PET-CT were identified.

Conclusion: Early postoperative PET-CT changed the staging and treatment of 13.4% of stage III CC patients and has the potential for early detection of curable metastatic disease. Outcome results are encouraging. Prospective validation is ongoing.
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http://dx.doi.org/10.1002/cam4.1818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6246942PMC
November 2018

Urgent Laparotomy in Patients with Metastatic Colorectal Cancer Presenting as an Acute Abdomen: A Retrospective Analysis.

Isr Med Assoc J 2018 Oct;20(10):619-622

Department of Surgery, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel.

Background: Unlike the elective treatment of metastatic colorectal cancer (MCRC), sufficient data and consensual guidelines on acute care are lacking.

Objectives: To analyze a cohort of MCRC patients who required urgent surgery due to acute abdomen and to identify risk factors contributing to the patient's perioperative mortality and morbidity.

Methods: A retrospective analysis was conducted of patients diagnosed with stage IV colorectal cancer who required urgent laparotomy at the Rabin Medical Center. Comparative analysis was performed using Pearson's chi-square and Student`s t-test.

Results: Between 2010 and 2015, 113 patients underwent urgent laparotomy due to colorectal cancer complications, of which 62 patients were found to have a metastatic, stage IV, disease. Large bowel obstruction was the most common indication for urgent laparotomy. In-hospital mortality was 30% (n=19), and overall 30 day mortality was 43%. Fifteen patients (24%) required more than one surgery. The average length of hospital stay was 21 days. Age and lactate levels at presentation were the only prognostic factor found for mortality (P < 0.05).

Conclusions: MCRC laparotomy patients incur a significant burden of care and have a relatively high incidence of early mortality. Our data suggest high, verging on unacceptable, mortality and complication rates in this subgroup of patients. This finding is further accentuated in the subgroup of older patients presenting with lactatemia. These data should be considered by surgeons when discussing treatment options with patients and families.
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October 2018

Laparoscopic hand-assisted liver resection for tumours in the left lateral section.

J Minim Access Surg 2020 Jan-Mar;16(1):35-40

Departments of Surgery, Rabin Medical Center, Petah-Tikva; Department of Surgery 'A', Carmel Medical Center, Tel Aviv University, Tel Aviv; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.

Context: The role of the laparoscopic left lateral sectionectomy (LLLS) is debatable, and Level-1 data are lacking.

Aims: The aim of the study is to evaluate the feasibility and safety of this approach.

Settings And Design: This was a retrospective study.

Subjects And Methods: From 2007 to 2014, patients undergoing LLLS were identified from two institutions.

Statistical Analysis Used: Continuous variables were compared between groups with Student's t-test or Mann-Whitney test, as appropriate by type of distribution. Categorical variables were compared with Chi-square or Fisher's exact test, depending on the number of observations.

Results: Thirty-eight patients were included in the study. The mean age was 63.5 + 13 years (range, 31-89), and the mean number of tumours was 1.7 + 1.5. Eleven (29%) patients underwent LLS combined with an additional liver resection (combined resections group). The mean duration of the operation and the mean estimated blood loss were significantly decreased in the LLS group compared to the combined resection group (101 + 71 min vs. 208 + 98 min and 216 + 217 ml vs. 450 + 223 ml;P < 0.05 for both, respectively). The major complications rate was 8% and no mortality occurred.

Conclusions: In a subset of carefully selected cases, LLLS may provide the benefits of laparoscopy. This does not appear to compromise perioperative morbidity rates. We believe that this approach may serve as a training platform for surgical trainees.
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http://dx.doi.org/10.4103/jmas.JMAS_148_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945333PMC
August 2018

Comparison between laparoscopic and open Hartmann's reversal: results of a decade-long multicenter retrospective study.

Surg Endosc 2018 12 15;32(12):4780-4787. Epub 2018 May 15.

Division of Surgery, Tel-Aviv Medical Center, Tel Aviv, Israel.

Background: Hartmann's reversal is a challenging surgical procedure with significant postoperative morbidity rates. Various surgical methods have been suggested to lower the risk of postoperative complications. In this study, we aimed to compare the postoperative results between open and laparoscopic techniques for Hartmann's reversal.

Methods: A retrospective study of all patients who underwent Hartmann's reversal in five centers in central Israel between January 2004 and June 2015 was conducted. Medical charts were reviewed, analyzing preoperative and operative parameters and short-term postoperative outcomes.

Results: 260 patients were included in the study. 76 patients were operated laparoscopically with a conversion rate of 26.3% (20 patients). No differences were found between patients operated laparoscopically and those operated in an open technique regarding gender (p = 0.785), age (61.34 vs. 62.64, p = 0.521), body mass index (26.6 vs. 26.2, p = 0.948), Charlson index score (1.79 vs. 1.95, p = 0.667), and cause for Hartmann's procedure (neoplastic vs. non-neoplastic, p = 0.644). No differences were seen in average time from the Hartmann's procedure to reversal (204.89 vs. 213.60 days, p = 0.688) and in overall complication rate (46.4 vs. 46.5%, p = 1). The Clavien-Dindo score for distinguishing between minor (0-2 score, p = 1) and major complications (3-5 score, p = 0.675) failed to demonstrate an advantage to laparoscopy, as well as to average length of stay (10.91 days in the laparoscopic group vs. 11.72 days in the open group, p = 0.529). An analysis based on the intention-to-treat with laparoscopy, including converted cases in the laparoscopic group, showed similar results, including overall complication rate (48.6 vs. 45.6%, p = 0.68) and Clavien-Dindo score in both minor (p = 0.24) and major complications (p = 0.44). Length of stay (10.92 vs. 11.81 days, p = 0.45) was also similar between the two groups.

Conclusion: In this series, a laparoscopic approach to Hartmann's reversal did not offer any short-term advantage when compared to an open surgical approach.
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http://dx.doi.org/10.1007/s00464-018-6227-8DOI Listing
December 2018

Esophageal Cancer in Israel has Unique Clinico-Pathological Features: A Retrospective Study.

J Cancer 2017 22;8(13):2417-2423. Epub 2017 Jul 22.

Institute of Oncology, Davidoff Center, Rabin Medical Center, Petach Tikva, Israel.

Data regarding esophageal cancer (EC) in Israel are limited. The aim of this study was hence to characterize this entity in the Israeli population and to compare it to the literature. This is a retrospective study of all consecutive EC patients treated at our institution between 1997-2013. Data were retrieved from patients' medical files. Two hundred patients were included. The median age at diagnosis was 70.5 years; 63.5% were males; 63% were Ashkenazi Jews, 29% were Sephardic Jews, and 0.5% were Arabs. Squamous cell carcinoma (SCC) was predominant: 52% versus 45.5% with adenocarcinoma (ADC). SCC was common even in the distal esophagus (45%). The overall 5-year survival rate was 25.5%. A temporal trend (2006-2013 vs 1997-2005) shows a decline in the proportion of SCC (47% vs 63%, p=0.061) and a rise in ADC (50% vs 33%, p=0.041), with a parallel decrease in patients' age (median: 68.5 vs 73 years, p=0.014). In the later period, patients received more treatment for localized and metastatic disease, with a trend for improved median survival (20.1 vs 14.9 months, p=0.658). Ashkenazi Jews were diagnosed at an older age than Sephardic Jews (median: 73 vs. 65 years, p=0.001), had a higher rate of family history of GI cancer (34% vs. 17%, p=0.026) and a higher rate of cardiovascular co-morbidity (41% vs. 24%, p=0.041). EC in Israel represents an intermediate entity between the Western and the endemic subtypes, showing some unique features. These included delayed reversal of the SCC/ADC ratio, commonness of SCC in the distal esophagus, prevalence of other malignancies and predominance of Ashkenazi ethnicity. The reason for these findings is unclear and its further evaluation is warranted.
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http://dx.doi.org/10.7150/jca.19210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5595070PMC
July 2017

Considerations for Hartmann's reversal and Hartmann's reversal outcomes-a multicenter study.

Int J Colorectal Dis 2017 Nov 6;32(11):1577-1582. Epub 2017 Sep 6.

Department of General Surgery and Transplantations B, Sheba Medical Center, Ramat Gan, Israel.

Purpose: Hartmann's procedure is commonly practiced in emergent cases with the restoration of bowel continuity planned at a second stage. This study assessed the rate of restorations following Hartmann's procedure and evaluated factors affecting decision-making.

Methods: Data on patient demographics, comorbidities, causes for Hartmann's procedure, reversal rate, and complications were collected in a multicenter retrospective cohort study of patients who underwent Hartmann's procedure in five medical centers.

Results: Six hundred forty patients underwent Hartmann's procedure for diverticular disease (36.1%), obstructing malignancy (31.8%), benign obstruction (5%), and other reasons (23.1%). Overall, 260 (40.6%) patients underwent subsequent restoration of bowel continuity. One hundred twenty-one (46.5%) patients had post-reversal complications, with an average Clavien-Dindo score of 1.4 and a mortality rate of 0.77%. Decision to avoid reversal was mostly related to comorbidities (49.7%) and metastatic disease (21.6%). Factors associated with the decision to restore bowel continuity included male gender (P = 0.02), patient age (62.3 years in Hartmann's reversal patients vs 73.5 years in non-reversal patients; P < 0.0001), number of comorbidities (1.1 vs 1.58; P < 0.001), average Charlson score (1.93 vs 3.44; P < 0.001), and a neoplastic etiology (P < 0.0001). A sub-analysis excluding all patients who died in the 30 days following Hartmann's procedure showed similar factors associated with ostomy closure.

Conclusion: Many patients do not have restoration of bowel continuity after undergoing Hartmann's procedure. Hartmann's reversal is associated with a significant postoperative morbidity. Surgeons and patients should be aware of the possibility that the colostomy might become permanent.
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http://dx.doi.org/10.1007/s00384-017-2897-2DOI Listing
November 2017

Gastrointestinal Stromal Tumor of Stomach: A Gentle Enemy of the Surgeon. Our Experience in Confronting the Disease.

Surg Laparosc Endosc Percutan Tech 2016 Oct;26(5):406-409

*Division of General Surgery †Institute of Pathology, Rabin Medical Center, Affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Surgical resection is considered to be the best treatment for gastrointestinal stromal tumor (GIST), the most common mesenchymal tumor of the gastrointestinal tract. Tumor size, mitotic rate, and anatomic locations are directly related to the potential malignancy, surgical approach, oncological treatment, and recurrence rate.

Materials And Methods: This was a retrospective study of 40 patients who underwent surgical resection of histologically or immunohistochemistry-proven GIST of the stomach at the Rabin and Kaplan Medical Center between 2004 and 2013. Tumor size, location, margin status, pathologic characteristics, surgical approach, surgical outcome, and long-term follow-up were analyzed from hospital records.

Results: The most common presentation was upper gastrointestinal bleeding (40%), although 30% of cases were asymptomatic. A laparoscopic approach was the preferred technique whenever feasible; 85% of tumors were localized in the proximal stomach, with a median size of 5.6 cm. Most of the resected tumors revealed a low mitotic rate and thus had low-moderate risks of malignancy. All tumors were completely resected with free surgical margins. The median follow-up period was 40 months with 93% disease-free survival.

Conclusions: Gastric GIST is a snake in the grass and its diagnosis is often incidental to endoscopy and computed tomographic scan. The most important technical point is to avoid tumor rupture during removal.
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http://dx.doi.org/10.1097/SLE.0000000000000317DOI Listing
October 2016

[LAPAROSCOPIC "SLEEVE" GASTRECTOMY POST HEART TRANSPLANTION].

Harefuah 2016 Mar;155(3):155-7, 196

Morbid obesity affects the function of the transplanted heart either directly, by damaging many elements that affect cardiac function or indirectly, by the initial appearance or worsening of co-morbidities that affect the heart. Bariatric surgery is the most effective treatment for a significant and sustained decrease in weight and it leads to the disappearance of co-morbidities such as diabetes, hypertension and dyslipidemia in high rates. These diseases can damage the blood vessels of the graft and impair its function. We report a case study of a 47-year-old morbidly obese male (BMI 36 kg/m2] who underwent heart transplantation three years previously, developed gradual weight gain and symptoms of aggravating heart failure. Coronary artery disease in the implanted heart was diagnosed. Clinically, he started suffering from shortness of breath and chest pain during minimal effort. In addition, he also suffered from high blood pressure and kidney failure. Laparoscopic sleeve gastrectomy was successfully performed and he was discharged four days later. On follow-up the patient has lost 35 kg. His present weight is 74 kg (BMI 25.7). All symptoms of heart failure improved and oral medications for hypertension and heart failure were withdrawn. Our conclusion is that it is justified to consider bariatric surgery in heart transplant recipients suffering from morbid obesity, as long as the long-term benefit outweighs the surgical risk. The decision to perform bariatric surgery should be made by a multidisciplinary team and the operation should take place at a center with extensive experience in bariatric surgery.
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March 2016

A novel method for screening colorectal cancer by infrared spectroscopy of peripheral blood mononuclear cells and plasma.

J Gastroenterol 2016 Mar 26;51(3):214-21. Epub 2015 Jun 26.

Department of Surgery B, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel.

Background: Early detection of colorectal cancer (CRC) can reduce mortality and morbidity. Current screening methods include colonoscopy and stool tests, but a simple low-cost blood test would increase compliance. This preliminary study assessed the utility of analyzing the entire bio-molecular profile of peripheral blood mononuclear cells (PBMCs) and plasma using Fourier transform infrared (FTIR) spectroscopy for early detection of CRC.

Methods: Blood samples were prospectively collected from 62 candidates for CRC screening/diagnostic colonoscopy or surgery for colonic neoplasia. PBMCs and plasma were separated by Ficoll gradient, dried on zinc selenide slides, and placed under a FTIR microscope. FTIR spectra were analyzed for biomarkers and classified by principal component and discriminant analyses. Findings were compared among diagnostic groups.

Results: Significant changes in multiple bands that can serve as CRC biomarkers were observed in PBMCs (p = ~0.01) and plasma (p = ~0.0001) spectra. There were minor but statistically significant differences in both blood components between healthy individuals and patients with benign polyps. Following multivariate analysis, the healthy individuals could be well distinguished from patients with CRC, and the patients with benign polyps were mostly distributed as a distinct subgroup within the overlap region. Leave-one-out cross-validation for evaluating method performance yielded an area under the receiver operating characteristics curve of 0.77, with sensitivity 81.5% and specificity 71.4%.

Conclusions: Joint analysis of the biochemical profile of two blood components rather than a single biomarker is a promising strategy for early detection of CRC. Additional studies are required to validate our preliminary clinical results.
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http://dx.doi.org/10.1007/s00535-015-1095-7DOI Listing
March 2016

[Learning curve in laparoscopic Roux-en-Y gastric bypass for the treatment of morbid obesity].

Harefuah 2015 Apr;154(4):254-8, 279

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently considered the gold standard treatment for morbid obesity. The learning curve for this procedure is about 100 cases, and it is considered the most important factor in decreasing complications and mortality. We present our experience and learning curve with LRYGB.

Methods: The data was collected prospectively. All patients with primary LRYGB between March 2006 and April 2014 were included. Only patients with full data on demographics, length of stay, operating time, and complications were included in the study.

Results: Five hundred and eleven patients underwent a LRYGB. Ninety five of them underwent a redo RYGB (conversion), and were excluded. Of the remaining 416 patients, full data was available for 326 and the statistical analysis refers to this group. The complication rate was available for all patients who were included in the study. The mean age and body mass index were 43 years (14-76 years) and 42.8 kg/m2 (34-76) respectively. The mean duration of surgery was 86 minutes (40-420). In the first 100 patients, operating time was 148 min, while in the last 125 patients it was 75 min. The major perioperative complication rate was 7.7%. Of 4 leaks (0.95%, 3 were encountered in the first 100 operations, and one in the following 316 (3% and 0.3% respectively). The mean length of stay was 2.2 days (1-46). None of the patients stayed in the intensive care unit. There was no mortality.

Conclusions: LRYGB is very safe. We confirm that the learning curve for this procedure is more than 100 cases. Appropriate training is crucial.
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April 2015

Early detection of breast cancer using total biochemical analysis of peripheral blood components: a preliminary study.

BMC Cancer 2015 May 15;15:408. Epub 2015 May 15.

Department Surgery B, Rabin Medical Center, Beilinson Campus, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Most of the blood tests aiming for breast cancer screening rely on quantification of a single or few biomarkers. The aim of this study was to evaluate the feasibility of detecting breast cancer by analyzing the total biochemical composition of plasma as well as peripheral blood mononuclear cells (PBMCs) using infrared spectroscopy.

Methods: Blood was collected from 29 patients with confirmed breast cancer and 30 controls with benign or no breast tumors, undergoing screening for breast cancer. PBMCs and plasma were isolated and dried on a zinc selenide slide and measured under a Fourier transform infrared (FTIR) microscope to obtain their infrared absorption spectra. Differences in the spectra of PBMCs and plasma between the groups were analyzed as well as the specific influence of the relevant pathological characteristics of the cancer patients.

Results: Several bands in the FTIR spectra of both blood components significantly distinguished patients with and without cancer. Employing feature extraction with quadratic discriminant analysis, a sensitivity of ~90 % and a specificity of ~80 % for breast cancer detection was achieved. These results were confirmed by Monte Carlo cross-validation. Further analysis of the cancer group revealed an influence of several clinical parameters, such as the involvement of lymph nodes, on the infrared spectra, with each blood component affected by different parameters.

Conclusion: The present preliminary study suggests that FTIR spectroscopy of PBMCs and plasma is a potentially feasible and efficient tool for the early detection of breast neoplasms. An important application of our study is the distinction between benign lesions (considered as part of the non-cancer group) and malignant tumors thus reducing false positive results at screening. Furthermore, the correlation of specific spectral changes with clinical parameters of cancer patients indicates for possible contribution to diagnosis and prognosis.
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http://dx.doi.org/10.1186/s12885-015-1414-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455613PMC
May 2015

Laparoscopic conversion of failed vertical banded gastroplasty to Roux-en-Y gastric bypass or biliopancreatic diversion.

Surg Obes Relat Dis 2015 Sep-Oct;11(5):1085-91. Epub 2015 Feb 11.

Department of Surgery Rabin Medical Center, Campus Beilinson, Petach Tiqva, Israel. Electronic address:

Background: The Silastic ring vertical gastroplasty (SRVG), a modification of Mason's vertical banded gastroplasty (VBG), was the restrictive procedure of choice for many bariatric surgeons. The reoperation rate for failure/complications reported in long-term studies is approximately 50%.

Objective: We report our experience in laparoscopic conversion of failed SRVG to Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD).

Setting: A single surgeon's experience at a university-affiliated hospital.

Methods: Between March 2006 and April 2014, 39 patients underwent conversion of SRVG to laparoscopic RYGB (n = 25) or BPD (n = 14). The outcomes were retrieved from a prospectively collected database and analyzed.

Results: Most (89%) of the conversions were completed laparoscopically. The mean operative time was 195 and 200 min for RYGB and BPD, respectively. There was no mortality. Complications occurred in 11 patients (28%), 5 in RYGB (19%) and 6 in BPD (42%). At the 3-year follow-up, the mean body mass index decreased from 47±8 kg/m(2) to 26±4 kg/m(2) for BPD, and from 43 kg/m(2) to 34 kg/m(2) (P = .05) for RYGB. Weight (kg) decreased from 110 to 84 and to 92, and from 123 to 81 and 68, at 1 and 3 years for RYGB and BPD, respectively.

Conclusions: The weight loss for RYGB and BPD was equal at 1 year but tended to be better for BPD at 3 years postoperatively. Laparoscopic conversion of failed VBG to RYGB or BPD was feasible, but it was followed by prohibitively high complication rates in BPD patients. The risk:benefit ratio of these procedures in this series is questionable.
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http://dx.doi.org/10.1016/j.soard.2015.01.026DOI Listing
September 2016

Early postoperative 18F-FDG PET/CT in high-risk stage III colorectal cancer.

Clin Nucl Med 2015 Apr;40(4):e222-7

From the *Department of Surgery B, Rabin Medical Center, Beilinson Campus, Petach Tikva; †Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; ‡Institute of Oncology, Davidoff Center; Departments of §Nuclear Medicine, and ║Radiology, Rabin Medical Center, Petach Tikva, Israel.

Purpose: PET/CT may contribute to staging modification in different phases of colorectal cancer (CRC) management. However, it is not routinely indicated for stage III CRC. This study sought to determine the role of early postoperative PET/CT in patients with high-risk stage III CRC.

Patients And Methods: The tumor registry of a tertiary medical center was searched (2004-2011) for all patients with stage III CRC who underwent early postoperative PET/CT because of the presence of high-risk factors for systemic disease. Demographic and clinicopathological characteristics were compared between patients found/not found to have metastatic disease.

Results: The cohort included 91 patients with a median age of 67 years (range, 29-90 years). Pathological FDG uptake was observed in 38 (41%). Of these, 14 (15% of the whole cohort) were upstaged with alteration of their treatment protocol, 10 (11%) had local postoperative changes, and 14 (15%) had false-positive findings. The sensitivity and specificity of PET/CT for detecting metastatic disease were 100% and 69%, respectively. Elevated postoperative carcinoembryonic antigen and CA-19.9 levels correlated with a positive PET/CT (P = 0.05 and P = 0.03, respectively). The median follow-up time was 34 months (range, 4-85 months). The estimated 5-year survival rate was significantly higher in patients with a negative than a positive scan (70% vs 42%, P < 0.0006).

Conclusions: Findings on early postoperative PET/CT may influence staging and treatment in 15% of selected patients with high-risk stage III CRC. Postoperative levels of carcinoembryonic antigen and CA-19.9 may serve as indications for PET/CT scanning in this setting. Prospective validation is warranted.
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http://dx.doi.org/10.1097/RLU.0000000000000692DOI Listing
April 2015
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