Publications by authors named "Nir Wasserberg"

66 Publications

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

Alteration in urease-producing bacteria in the gut microbiomes of patients with inflammatory bowel diseases.

J Crohns Colitis 2021 Jun 10. Epub 2021 Jun 10.

Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel.

Background And Aims: Bacterial urease is a major virulence factor of human pathogens, and murine models have shown that it can contribute to the pathogenesis of inflammatory bowel diseases [IBD].

Methods: The distribution of urease-producing bacteria in IBD was assessed using public fecal metagenomic data from various cohorts, including non-IBD controls (n = 55), patients with Crohn's disease (n = 291), ulcerative colitis (n = 214), and patients with a pouch (n = 53). The ureA gene, and the taxonomic markers gyrA, rpoB and recA were used to estimate the percentage of urease producers in each sample.

Results: Levels of urease producers in patients with IBD and non-IBD controls were comparable. In non-IBD controls and most IBD patients, urease-producers were primarily acetate producing genera such as Blautia and Ruminococcus. A shift in the type of the dominant urease producers towards Proteobacteria and Bacilli was observed in a subset of all IBD subtypes, which correlated with fecal calprotectin levels in one cohort. Some patients with IBD had no detectable urease producers.In patients with a pouch the probiotic-associated species Streptococcus thermophilus was more common as a main urease producer than in other IBD phenotypes, and it generally did not co-occur with other Bacilli or with Proteobacteria.

Conclusions: Unlike all non-IBD controls, patients with IBD often showed a shift towards Bacilli or Proteobacteria or a complete loss of urease production. Probiotics containing the species S. thermophilus may have a protective effect against colonization by undesirable urease-producing bacteria in a subset of patients with a pouch.
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http://dx.doi.org/10.1093/ecco-jcc/jjab101DOI Listing
June 2021

Dysbiosis in Metabolic Genes of the Gut Microbiomes of Patients with an Ileo-anal Pouch Resembles That Observed in Crohn's Disease.

mSystems 2021 Mar 2;6(2). Epub 2021 Mar 2.

Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel-Aviv University, Tel Aviv, Israel

Crohn's disease (CD), ulcerative colitis (UC), and pouchitis are multifactorial and chronic inflammatory bowel diseases (IBD). Pouchitis develops in former UC patients after proctocolectomy and ileal-pouch-anal anastomosis and is characterized by inflammation of the previously normal small intestine comprising the pouch. The extent to which microbial functional alteration (dysbiosis) in pouchitis resembles that of CD or UC has not been investigated, and the pathogenesis of pouchitis remains unknown. We collected 208 fecal metagenomes from 69 patients with a pouch (normal pouch and pouchitis) and compared them to publicly available metagenomes of patients with CD ( = 88), patients with UC ( = 76), and healthy controls ( = 56). Patients with pouchitis presented the highest alterations in species, metabolic pathways, and enzymes, which was correlated with intestinal inflammation. strains encoding mucin-degrading glycoside hydrolases were highly enriched in pouchitis. Butyrate and secondary bile acid biosynthesis pathways were decreased in IBD phenotypes and were especially low in pouchitis. Pathways such as amino acid biosynthesis and degradation of aromatic compounds and sugars, encoded by members of the , were enriched in pouch and CD but not in UC. We developed microbial feature-based classifiers that can distinguish between patients with a normal pouch and pouchitis and identified species and genes that were predictive of pouchitis. We propose that the noninflamed pouch is already dysbiotic and microbially is similar to CD. Our study reveals microbial functions that outline the pathogenesis of pouchitis and suggests bacterial groups and functions that could be targeted for intervention to attenuate small intestinal inflammation present in pouchitis and CD. Crohn's disease (CD), ulcerative colitis (UC), and pouchitis are chronic inflammatory conditions of the bowel. Pouchitis develops in former UC patients after proctocolectomy and ileal-pouch-anal anastomosis and is characterized by inflammation of the previously normal small intestine comprising the pouch. The extent to which microbial dysbiosis in patients with pouchitis resembles that of CD or UC and the pathogenesis of pouchitis remains unclear. We investigated the functions in the gut microbiomes of these patients using metagenomics. We found that the noninflamed pouch is already dysbiotic and microbially is similar to CD. Our study reveals microbial functions with a potential role in pouchitis pathogenesis such as depletion in butyrate and secondary bile acid synthesis and enrichment of amino acid synthesis and degradation of aromatic compounds, encoded by members of the We developed microbial feature-based classifiers that can distinguish between patients with a normal pouch and pouchitis and identified species and genes that were predictive of pouchitis. We suggest species and functions that could be targeted for intervention to attenuate small intestinal inflammation present in pouchitis and CD.
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http://dx.doi.org/10.1128/mSystems.00984-20DOI Listing
March 2021

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

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

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

Erratum to: "Immunohistochemistry staining for mismatch repair proteins: the endoscopic biopsy material provides useful and coherent results" [Hum Pathol 2015;46:1705-1711].

Hum Pathol 2017 09 7;67:229. Epub 2017 Sep 7.

The Gastroenterology Department, Beilinson Hospital, Petah Tiqva, PO 49100, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, PO 69978, Israel. Electronic address:

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http://dx.doi.org/10.1016/j.humpath.2017.08.014DOI Listing
September 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

Changing paradigms in the management of diverticulitis.

Int J Surg 2016 Sep 2;33 Pt A:146-50. Epub 2016 Aug 2.

Department of Surgery and Transplantation, Chaim Sheba Medical Center Ramat Gan Israel (affiliated to the Faculty of Medicine, Tel Aviv University), Israel.

The management of diverticular disease has evolved in the last few decades from a structured therapeutic approach including operative management in almost all cases to a variety of medical and surgical approaches leading to a more individualized strategy. There is an ongoing debate among surgeons about the surgical management of diverticular disease, questioning not only the surgical procedure of choice, but also about who should be operated and the timing of surgery, both in complicated and uncomplicated diverticular disease. This article reviews the current treatment of diverticulitis, with a focus on the indications and methods of surgery in both the emergency and elective settings. Further investigation with good clinical data is needed for the establishment of clear guidelines.
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http://dx.doi.org/10.1016/j.ijsu.2016.07.072DOI Listing
September 2016

Feasibility of an Intraluminal Bypass Device in Low Colorectal Anastomosis: Preliminary Results in a Porcine Model.

Surg Innov 2016 Jun 24;23(3):298-304. Epub 2015 Nov 24.

Tel Aviv University, Tel Aviv, Israel Tel Aviv Medical Center, Tel Aviv, Israel.

Background: The Cologuard CG-100 is a novel intraluminal bypass device designed to reduce the clinical outcomes associated with low colorectal anastomotic leak. The device is inserted transanally, anchored to the colon above the anastomosis, and deployed intraluminally to cover the anastomosis from within. The purpose of this study was to evaluate the safety and performance of the device in a porcine model.

Method: Twelve pigs underwent low colorectal anastomosis with insertion of the Cologuard CG-100 device. Contrast material injection, abdominal X-ray, and histologic studies were used to evaluate sealing quality, device positioning, and tissue damage, respectively. The surgeons completed a usability and satisfaction questionnaire after completion of the procedure.

Results: Absolute sealing was observed in all 4 animals euthanized immediately after surgery. In the other 8 animals, the device was kept in situ for 10 days and then extracted. X-ray films with injection of contrast material through a designated injection tube before device removal showed that the sheath and ring were correctly placed. No leak was demonstrated. There were no device-related adverse events, and no critical histological abnormalities were noted in the bowel area that was compressed by the device. The device was found to be easy to insert, position, and extract.

Conclusion: The Cologuard CG-100 device efficiently reduced contact between fecal content and low colorectal anastomosis in a porcine model and is easily deployed and extracted. It holds promise for possible clinical use pending further studies.
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http://dx.doi.org/10.1177/1553350615617250DOI Listing
June 2016

Immunohistochemistry staining for mismatch repair proteins: the endoscopic biopsy material provides useful and coherent results.

Hum Pathol 2015 Nov 29;46(11):1705-11. Epub 2015 Jul 29.

The Gastroenterology Department, Beilinson Hospital, Petah Tiqva, PO 49100, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, PO 69978 Israel. Electronic address:

Immunohistochemistry (IHC) testing for mismatch repair proteins (MMRP) in patients with colorectal cancer can be performed on endoscopic biopsy material or the surgical resection material. Data are continuing to accumulate regarding the deleterious effect of neoadjuvant chemoradiation on MMRP expression. However, despite continuing rise in the use of endoscopic biopsies for IHC, most pathology departments still use mainly the surgical materials for IHC testing. In this study we compared the quality of stains among 96 colon cancer subjects with paired endoscopic and surgical material available for MLH1, MSH2, MSH6, and PMS2 stains (96 × 4, yielding 384 paired stains). Each slide received both a quantitative score (immunoreactivity [0-3] × percent positivity [0-4]) and a qualitative score (absent; weak and focal; strong). The quantitative scores of all MMRP were significantly higher among the endoscopic material (P<.001 for all). In 358 pairs (93.2%), both the endoscopic and operative material stained either strong (322, 83.9%) or absent (36, 9.4%). In 26 pairs (6.8%), the endoscopic material stained strong, whereas the operative material stained focal and weak. No endoscopic biopsy materials stained focal and weak. Our findings indicate that the biopsy material may provide more coherent results. Although these results may indicate that biopsy material provides coherent and useful results, it is yet to be determined if the demonstrated differences pose a real clinical problem in interpreting final results of IHC staining of such kind. Hence, we suggest that when available, the endoscopic material rather than the operative one should serve as the primary substrate for IHC staining.
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http://dx.doi.org/10.1016/j.humpath.2015.07.009DOI Listing
November 2015

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

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

Acute appendicitis in the elderly in the twenty-first century.

J Gastrointest Surg 2015 Apr 14;19(4):730-5. Epub 2015 Feb 14.

Department of Surgery, Chaim Sheba Medical Center, Tel Hashomer, Israel.

Background: The incidence of appendicitis in the elderly has risen. Older age is an independent predictor of poor surgical outcome. Herein, we present the most comprehensive single institution study to describe the natural history and outcome of appendicitis in elderly patients.

Methods: A review of 1898 consecutive patients who underwent appendectomy between 2004 and 2007 was performed. The elderly patients were defined as older than 68 years.

Results: The median age of the entire cohort was 25 years, and 55% were males. The elderly group included 68 patients (3.6%). On comparison by age, the elderly group had a significantly longer delay from symptom onset to admission (50 vs. 31 h, P = 0.01) and from admission to surgery, a longer operative time and hospital stay, and higher rates of postoperative complications and complicated appendicitis.

Conclusion: The current study demonstrated several unique characteristics of the elderly population with acute appendicitis, which include poor outcome and longer time intervals to diagnosis and treatment. In order to improve the poor outcome of the elderly population with appendicitis, prospective trials are necessary.
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http://dx.doi.org/10.1007/s11605-014-2716-9DOI Listing
April 2015

Home electrical stimulation for women with fecal incontinence: a preliminary randomized controlled trial.

Int J Colorectal Dis 2015 Apr 27;30(4):521-8. Epub 2015 Jan 27.

Physiotherapy Service, Rabin Medical Center, Petach Tikva, Israel.

Purpose: The purpose of this study is to compare the effectiveness and cost of home electrical stimulation and standardized biofeedback training in females with fecal incontinence

Methods: Thirty-six females suffering from fecal incontinence were randomized into two groups, matched for mean age (67.45 ± 7.2 years), mean body mass index (kg/m2) (26.2 ± 3.9), mean disease duration (4.1 ± 0.8 years), mean number of births (2.7 ± 1.3), and reports of obstetric trauma (25%). Questionnaires were used to evaluate their demographics, medical, and childbearing history. Subjects were randomized to home electrical stimulation or standardized biofeedback training for a period of 6 weeks. Subjective outcome measures included the frequency of fecal, urine, and gas incontinence by visual analog scale, Vaizey incontinence score, and subjects' levels of fecal incontinence related anxiety. Objective outcome measures included pelvic floor muscle strength assessed by surface electromyography. We also compared the cost of each treatment modality.

Results: Only females who received home electrical stimulation (HES) reported a significant improvement in Vaizey incontinence score (p = 0.001), anxiety (p = 0.046), and in frequency of leaked solid stool (p = 0.013). A significant improvement in pelvic floor muscle strength was achieved by both groups. HES was much cheaper compared to the cost of standardized biofeedback training (SBT) (US $100 vs. US $220, respectively). Our study comprised a small female population, and the study endpoints did not include objective measures of anorectal function test, such as anorectal manometry, before and after treatment.

Conclusions: Home electrical stimulation may offer an alternative to standardized biofeedback training as it is effective and generally well-tolerated therapy for females with fecal incontinence.
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http://dx.doi.org/10.1007/s00384-015-2128-7DOI Listing
April 2015

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

The role of bariatric surgery in morbidly obese patients with inflammatory bowel disease.

Surg Obes Relat Dis 2015 Jan-Feb;11(1):132-6. Epub 2014 Aug 1.

Department of Surgery, Beilinson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Bariatric surgery is considered as being contraindicated for morbidly obese patients who also have inflammatory bowel disease (IBD). The aim of our study was to report the outcomes of bariatric surgery in morbidly obese IBD patients.

Methods: The prospectively collected data of all the patients diagnosed as having IBD who underwent bariatric operations in 2 medical centers between October 2006 and January 2014 were retrieved and analyzed.

Results: One male and 9 female morbidly obese IBD patients (8 with Crohn's disease and 2 with ulcerative colitis) underwent bariatric surgery. Their mean age was 40 years, and their mean body mass index was 42.6 kg/m2. Nine of them underwent a laparoscopic sleeve gastrectomy and 1 underwent a laparoscopic adjustable gastric band. Eight patients had obesity-related co-morbidities, including type 2 diabetes, hypertension, sleep apnea, osteoarthropathy, etc. After a median follow-up of 46 months (range 9-67), all of the patients lost weight, with an excess weight loss of 71%, and 10 out of 16 obesity-related co-morbidities were resolved. There was 1 complication not related to IBD, and no IBD exacerbation.

Conclusion: Bariatric surgery was safe and effective in our morbidly obese IBD patients. The surgical outcome in this selected patient group was similar to that of comparable non-IBD patients.
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http://dx.doi.org/10.1016/j.soard.2014.06.022DOI Listing
January 2016

Sphincter preservation in distal CT2N0 rectal cancer after preoperative chemoradiotherapy.

Radiat Oncol 2014 Oct 22;9:233. Epub 2014 Oct 22.

Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva, 49100, Israel.

Background: Preoperative chemoradiotherapy is usually not indicated for cT2N0 rectal cancer. Abdominoperineal resection is the standard treatment for distal rectal tumors. The aim of the study was to evaluate the actual sphincter-preservation rate in patients with distal cT2N0 rectal cancer given neoadjuvant chemoradiotherapy.

Methods: Data were retrospectively collected for all patients who were diagnosed with distal cT2N0 rectal cancer at a tertiary medical center in 2000-2008 and received chemoradiotherapy followed by surgery (5-7 weeks later).

Results: Thirty-three patients (22 male) of median age 65 years (range, 32-88) were identified. Tumor distance from the anal verge ranged from 0 to 5 cm. R0 resection with sphincter preservation was accomplished in 22 patients (66%), with a 22% pathological complete response rate. Median follow-up time was 62 months (range 7-120). There were no local failures. Crude disease-free and overall survival were 82% and 86%, respectively. Factors associated with sphincter preservation were tumor location (OR=0.58, p=0.02, 95% CI=0.37-0.91) and pathological downstaging (OR=7.8, p=0.02, 95% CI=1.35-45.85). Chemoradiotherapy was well tolerated.

Conclusion: High rates of sphincter preservation can be achieved after preoperative chemoradiotherapy for distal cT2N0 rectal cancer, with tolerable toxicity, without compromising oncological outcome.
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http://dx.doi.org/10.1186/s13014-014-0233-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4215010PMC
October 2014

Interval to surgery after neoadjuvant treatment for colorectal cancer.

Authors:
Nir Wasserberg

World J Gastroenterol 2014 Apr;20(15):4256-62

Nir Wasserberg, Department of Surgery B, Rabin Medical Center, Beilinson Campus, Petach Tikva and Sackler School of Medicine, Tel Aviv University, 69978 Tel Aviv, Israel.

The current standard treatment of low-lying locally advanced rectal cancer consists of chemoradiation followed by radical surgery. The interval between chemoradiation and surgery varied for many years until the 1999 Lyon R90-01 trial which compared the effects of a short (2-wk) and long (6-wk) interval. Results showed a better clinical tumor response (71.7% vs 53.1%) and higher rate of positive and pathologic tumor regression (26% vs 10.3%) after the longer interval. Accordingly, a 6-wk interval between chemoradiation and surgery was set to balance the oncological results with the surgical complexity. However, several recent retrospective studies reported that prolonging the interval beyond 8 or even 12 wk may lead to significantly higher rates of tumor downstaging and pathologic complete response. This in turn, according to some reports, may improve overall and disease-free survival, without increasing the surgical difficulty or complications. This work reviews the data on the effect of different intervals, derived mostly from retrospective analyses using a wide variation of treatment protocols. Prospective randomized trials are currently ongoing.
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http://dx.doi.org/10.3748/wjg.v20.i15.4256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3989961PMC
April 2014

Hand-assisted laparoscopic colectomy for colovesical fistula associated with diverticular disease.

Surg Laparosc Endosc Percutan Tech 2014 Jun;24(3):251-3

Departments of *Surgery B, Rabin Medical Center, Beilinson Campus, Petach Tikva †Shiba Medical Center, Tel Hashomer ‡Meir Medical Center, Kfar Saba, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

To evaluate the feasibility and short-term outcome of hand-assisted laparoscopic colectomy (HALC) for the treatment of colovesical fistula complicating diverticulitis, we reviewed the files of all 34 patients who underwent surgery for diverticular colovesical fistula in 1999 to 2010 at a major tertiary medical center. Twenty-one were treated with HALC and 13 with open colectomy. There were no differences in demographic parameters among the groups. HALC and open colectomy had similar operating time. HALC was associated with a significantly shorter hospital stay compared with open colectomy (5 vs. 8 d, P=0.001). HALC proved to be technically feasible and safe in this setting. It provided benefits of tactile feedback and manual manipulation as in open colectomy while maintaining the advantages of a minimal invasive approach.
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http://dx.doi.org/10.1097/SLE.0b013e31828f6ce0DOI Listing
June 2014

Laparoscopic total gastrectomy with Roux-y esophagojejunostomy for chronic gastric fistula after laparoscopic sleeve gastrectomy.

Obes Surg 2014 Mar;24(3):425-9

The Department of Surgery, Rabin Medical Center, Campus Beilinson, Petach Tiqva, Israel,

Laparoscopic sleeve gastrectomy is a restrictive operation with hormonal elements that is rapidly gaining popularity. The most feared complication of the procedure is a staple line leak. The treatment of staple line leakage depends on timing and clinical and anatomical considerations. If leakage persists and transforms into a chronic fistula, a definitive surgical procedure is required. In cases where the fistula originates close to the esophagogastric junction, the surgical possibilities are limited and one treatment option is total gastrectomy with esophagojejunal anastomosis. We report a case series of four patients with chronic fistulae, who failed conservative treatment and required total gastrectomy. Their average length of hospital stay was 8.7 days (range, 5-15 days), without conversions, leaks, or other complications. In experienced hands, total gastrectomy is feasible by laparoscopic techniques and should be performed soon after the fistula is established.
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http://dx.doi.org/10.1007/s11695-013-1162-1DOI Listing
March 2014

Restaging locally advanced rectal cancer by different imaging modalities after preoperative chemoradiation: a comparative study.

Radiat Oncol 2013 Nov 29;8:278. Epub 2013 Nov 29.

Department of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petach Tikva 49100, Israel.

Background: To compare the accuracy of different imaging modalities, alone and in combination in predicting findings at surgery after preoperative chemoradiation for locally advanced rectal cancer.

Methods: Following chemoradiation, tumors were reclassified on the basis of findings on pelvic computed tomography (CT) (94 patients), endorectal ultrasonography (EUS) (138 patients) alone or by both CT and EUS (80 patients). The ability of the imaging modalities, to predict the pathologic T status, N status, and TNM stage at surgery was evaluated and compared.

Results: Mean age of the patients was 64.5 years (range 28-88 years); 55% were male. CT and EUS combined had a positive predictive value of 20% for pathologic pT1 stage, 29% for pT1, 29% for pT2, and 58% for pT3. Predictive values for the operative TNM stage were 50% for stage I, 45% for stage II, and 31% for stage III. These values did not exceed those for each modality alone.

Conclusion: The performance of preoperative CT and EUS in predicting the T and TNM stage of rectal cancer at surgery is poor. Neither modality alone nor the two combined is sufficiently accurate to serve as the basis for decisions regarding treatment modification.
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http://dx.doi.org/10.1186/1748-717X-8-278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4222036PMC
November 2013

Laparoscopic accuracy in prediction of appendiceal pathology: oncologic and inflammatory aspects.

Am J Surg 2013 Nov 6;206(5):805-9. Epub 2013 Sep 6.

Department of Surgery, Rabin Medical Center, Beilinson Campus, Petach Tikva 49100, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address:

Background: In the prelaparoscopy era, macroscopically normal appendices were routinely resected. The aim of this study was to evaluate the accuracy of laparoscopy.

Methods: A review of 1,899 patients who underwent appendectomy with multivariate analysis was conducted.

Results: Laparoscopic and open approaches had similar false-positive rates, false-negative rates, accuracy, and sensitivity. The study population included 17 false-negative cases (11% of all macroscopically normal appendices). Tumors were found in 1.1% of our study population. Female gender (1.9% vs. .5%; odds ratio, 4; 95% confidence interval, 1.5 to 11; P < .005) and appendiceal perforation were independent risk factors for harboring a tumor.

Conclusions: It is suggested that laparoscopy has diagnostic quality similar to that of the open approach. Until randomized trials evaluate the fate of patients who receive false-negative diagnoses, routine appendectomy is recommended. Special attention should be paid to female patients and to patients with perforations, who have a 4-fold increased risk for harboring a tumor.
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http://dx.doi.org/10.1016/j.amjsurg.2013.05.002DOI Listing
November 2013

Acute appendicitis in the twenty-first century: should we modify the management protocol?

J Gastrointest Surg 2013 Aug 24;17(8):1462-70. Epub 2013 May 24.

Department of Surgery, Rabin Medical Center, Beilinson Campus, Petach-Tiqva, 49100, Israel.

Background: Recent data challenge the traditional management of acute appendicitis with early surgical intervention. This study evaluated the impact of timing of appendectomy and other potential risk factors on progression of acute appendicitis.

Study Design: A search of the relevant databases of a tertiary medical center identified 1,604 patients with verified acute appendicitis who underwent appendectomy in 2004-2007. Demographic and clinical data and time from symptom onset to emergency room admission ("patient interval") and from emergency room admission to surgery ("hospital interval") and their combination were analyzed by pathological grade.

Results: On multivariate analyses, independent risk factors for appendiceal perforation were age <20 years (OR = 1.58, 95 % CI 1.07-2.35) or >50 years (OR = 2.84, 95 % CI 1.82-4.45) (relative to 20-50 years), white cell count >10 × 103/mm(3) (OR = 4.45, 95 % CI 2.05-9.67), body temperature >37.8 °C (OR = 2.23, 95 % CI 1.45-3.41), hospital interval >24 h (OR = 2.84, 95 % CI 1.49-5.4), patient interval >48 h (OR = 3.84, 95 % CI 2.35-6.29), and combined interval >48 h (OR = 4.29, 95 % CI 2.2-8.36). No association with perforation was found for the hour of emergency room arrival, hour of operation, surgical approach, or the performance of preoperative imaging.

Conclusions: In the general population, the risk of advanced pathological grade of appendicitis increases with time. Thus, prompt appendectomy is warranted. Prospective studies of subgroups of perforated and nonperforated appendicitis are needed.
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http://dx.doi.org/10.1007/s11605-013-2232-3DOI Listing
August 2013

Third and fourth degree perineal tears--the risk of recurrence in subsequent pregnancy.

J Matern Fetal Neonatal Med 2014 Jan 14;27(2):177-81. Epub 2013 Jun 14.

Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva and.

Objective: To assess the risk of recurrence of third- and fourth-degree perineal tears (34DPT) and to determine whether previous 34DPT is an independent risk factor for 34DPT in subsequent deliveries.

Method: The study group included all women who had a vaginal delivery complicated by 34DPT (2000-2012, N = 356) and subsequently delivered again in the same medical center (N = 204). The rate of recurrence of 34DPT was compared with a control group of women who had a previous vaginal delivery not complicated by 34DPT (N = 58 581) and had a subsequent delivery in the same time period (N = 23 045).

Results: Women in the past-34DPT group had a higher rate of CS (18.6% versus 10.1%, p < 0.001), fetal head in occiput-posterior position (POP; 2.5% versus 0.7%, p = 0.004) and mediolateral episiotomy (25.5% versus 19.4%, p = 0.03). Women in the past-34DPT group had a higher rate of 34DPT in the subsequent delivery (2.0% versus 0.3%, p < 0.001). The rate of recurrence of 34DPT was considerably higher among women with past fourth-degree tear versus women with past third-degree tear (22.2% versus 1.0%, p < 0.001). 34DPT in previous pregnancy is independently associated with increased risk of 34DPT in subsequent delivery (OR = 4.6, 95%-CI 1.3-15.3).

Conclusion: Women who experienced 34DPT in their previous pregnancy have an increased risk for recurrence of 34DPT in subsequent pregnancy, especially in cases of past fourth-degree tears.
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http://dx.doi.org/10.3109/14767058.2013.806902DOI Listing
January 2014

Perforation and mortality after cleansing enema for acute constipation are not rare but are preventable.

Int J Gen Med 2013 26;6:323-8. Epub 2013 Apr 26.

Risk Management and Quality Assurance, Beilinson Hospital and Tel Aviv University, Tel Aviv, Israel.

Objectives: Constipation is a common complaint, frequently treated with cleansing enema. Enemas can be very effective but may cause serious adverse events, such as perforation or metabolic derangement. Our aim was to evaluate the outcome of the use of cleansing enema for acute constipation and to assess adverse events within 30 days of therapy.

Methods: We performed a two-phase study: an initial retrospective and descriptive study in 2010, followed by a prospective study after intervention, in 2011. According to the results of the first phase we established guidelines for the treatment of constipation in the Emergency Department and then used these in the second phase.

Results: There were 269 and 286 cases of severe constipation in the first and second periods of the study, respectively. In the first study period, only Fleet® Enema was used, and in the second, this was changed to Easy Go enema (free of sodium phosphate). There was a 19.2% decrease in the total use of enema, in the second period of the study (P < 0.0001). Adverse events and especially, the perforation rate and the 30-day mortality in patients with constipation decreased significantly in the second phase: 3 (1.4%) versus 0 (P = 0.0001) and 8 (3.9%) versus 2 (0.7%) (P = 0.0001), for perforation and death in the first and second period of the study, respectively.

Conclusion: Enema for the treatment of acute constipation is not without adverse events, especially in the elderly, and should be applied carefully. Perforation, hyperphosphatemia (after Fleet Enema), and sepsis may cause death in up to 4% of cases. Guidelines for the treatment of acute constipation and for enema administration are urgently needed.
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http://dx.doi.org/10.2147/IJGM.S44417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3641812PMC
May 2013

Grading of complications and risk factor evaluation in laparoscopic colorectal surgery.

Surg Endosc 2013 Oct 1;27(10):3748-53. Epub 2013 May 1.

Department of Surgery, Tel-Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

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.
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http://dx.doi.org/10.1007/s00464-013-2960-1DOI Listing
October 2013

Healing of ileocolic nitinol compression anastomosis: a novel porcine model of subtotal colectomy.

Surg Innov 2013 Dec 10;20(6):570-9. Epub 2013 Apr 10.

1Dept. of surgery B', HaEmek medical center, Faculty of medicine of the Technion, Israel institute of technology.

Background: There are limited large animal models for the research of novel anastomotic technologies. Subtotal colectomy requires the anastomosis of relatively remote segments of the alimentary tract that are different anatomically, histologically, and pose significant physiological challenge. The quest for a foreign material-free anastomotic line reintroduced nitinol compression anastomosis into clinical use in the last decade.

Objective: To evaluate the safety, histological, and physiological parameters of side-to-side ileocolic nitinol compression anastomosis in a newly developed large animal model, mimicking the human subtotal colectomy.

Intervention: Resection of the entire spiral colon with an ileocolic side-to-side compression anastomosis in 12 animals, compared to resection of a short ileal segment in 6 animals. All anastomoses were constructed by using a novel nitinol-based compression device. The animals were followed up to 30 days postoperatively and were reoperated and sacrificed.

Results: All 12 animals underwent successful subtotal colectomy with side-to-side nitinol compression anastomosis. No signs of abdominal infection were found. The increase in the colectomized animals' bodyweight over the postoperative course was significantly lower and the animals presented with longer periods of diarrhea. The histopathology revealed minimal inflammation and foreign body reaction with good alignment of the bowel wall layers in both groups. The anastomotic line width was shown to be reduced during the healing course of the compression anastomoses.

Conclusions: Side-to-side nitinol compression anastomosis is safe and demonstrates favorable functional and histopathological features. The porcine model of subtotal colectomy can be used for further research of novel anastomotic technologies.
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http://dx.doi.org/10.1177/1553350613484592DOI Listing
December 2013

Third- and fourth-degree perineal tears--incidence and risk factors.

J Matern Fetal Neonatal Med 2013 May 12;26(7):660-4. Epub 2012 Dec 12.

Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva and Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel.

Objective: To assess the incidence and risk factors for third- and fourth-degree perineal tears (34DPT), and to identify subgroups of women who are at especially high risk for 34DPT.

Methods: A cohort study of women who underwent vaginal delivery in a single tertiary medical center between 1999 and 2011, (58 937 deliveries). Women diagnosed with 34DPT following delivery were compared to control group. Multivariate logistic regression analysis and tree classification analysis were used to identify combinations of risk factors which were associated with considerable risk for 34DPT.

Results: Overall, 356 (0.6%) deliveries were complicated by 34DPT (340 (95.5%) third-degree tears and 16 (4.5%) fourth-degree tears). Independent predictors of 34DPT were: forceps delivery (odds ratio (OR) = 5.5, confidence interval (CI) 3.9-7.8), precipitate labor (OR = 5.2, CI 2.9-9.2), persistent occiput posterior position (OR = 2.6, CI 1.6-4.3), vacuum extraction (OR = 1.9, CI 1.4-2.6) as well as large for gestational age (LGA) infant and gestational age > 40 weeks. Fourth-degree tears were associated with forceps delivery (OR = 12.5, CI 2.3-66.2), precipitate labor (OR = 9.7, 95%-CI 1.2-75.4) and LGA infant (OR = 7.4, 95%-CI 1.7 -1.5). Overall, the predictability of 34DPT was limited (R(2 )= 0.4). In subgroups of women with certain combinations of risk factors the risk of 34DPT ranged from 10% to 25%.

Conclusion: Despite the limited predictability of 34DPT by individual risk factors, the use of combinations of risk factors may assist obstetricians in identifying women who are at especially high risk for 34DPT.
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http://dx.doi.org/10.3109/14767058.2012.746308DOI Listing
May 2013
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