Breast Cancer in Men: A Single Center Experience Over a Period of 22 years.

BACKGROUND: Male breast cancer (MBC) is a rare disease that is poorly understood. Treatment protocols are widely extrapolated from breast cancer in women. OBJECTIVES: To review the experience with MBC of a single center in Israel over a period of 22 years. METHODS: This single center retrospective study evaluated all patients diagnosed with MBC over a period of 22 years (1993-2015). Data were extracted from patient medical charts and included demographics, clinical, surgical, and oncological outcomes. RESULTS: The study comprised 49 patients. Mean age at diagnosis was 64.1 ± 13.5 years. The majority were diagnosed at early stages (1A-2A) (54.4%), 30.6% were stage 3B mostly due to direct skin and nipple involvement, and 59.2% of the patients had node negative disease. All of the patients were diagnosed with invasive ductal carcinoma and 30.6% had concomitant ductal carcinoma in situ. Estrogen receptor (ER) status was predominantly positive and luminal B (HER2-) was the most common subtype. Of the patients, 18.4% were BRCA carriers. The majority of patients underwent mastectomy. Radiotherapy was delivered to 46.9% and hormonal therapy to 89.8%. Chemotherapy was administered to 42.9%. Overall survival was 79.6% with a median survival of 60.1 (2-178) months; 5- and 10-year survival was 93.9% and 79.6%, respectively. Progesterone receptor (PR)-negative patients had a significantly improved overall survival. CONCLUSIONS: MBC has increasing incidence. PR-negative status was associated with better overall survival and disease-free interval. Indications to radiotherapy and hormonal therapy need standardization and will benefit from prospective randomized control trials.

[THE EFFECTS OF HORMONAL REPLACEMENT THERAPY (HRT) ON MAMMOGRAPHIC BREAST DENSITY AND ABNORMAL MAMMOGRAMS PROMPTING FURTHER INVESTIGATION].

AIMS: The purpose of this study was to portray and analyze the inter-relationship between the use of HRT, mammographic breast density and the finding of any mammographic abnormality that prompted further investigation such as core needle biopsy or additional imaging testing, while controlling for obstetric and relevant demographic data. BACKGROUND: Mammographic breast density has been associated with higher risk of breast cancer and decrease in its sensitivity, while hormonal replacement therapy (HRT) in turn, has been implicated in increasing mammographic density and is considered a risk factor for breast cancer by itself. The inter-relationship between HRT, breast density and any mammographic or sonographic finding requiring further investigation has not been fully investigated. METHODS: A total of 2,758 consecutive, screening mammograms performed during one year in a single academic medical center in Israel were analyzed. Each mammogram was supplemented by high resolution ultrasound. Density was measured by a visual, semi-quantitative, 5-grade scale, based on Boyd's classification and grouped into low density mammograms (LDM) (1-3) and high density mammograms (HDM) (4-5). Demographic and obstetric data, personal and family history of breast cancer, and the use of HRT were entered into the database. These parameters were correlated with breast density and any detected abnormality that prompted further investigation. Univariate and multivariate analyses as well as multivariate logistic regression were performed using SAS 9.2. RESULTS: A significant difference in density was observed between pre- and post-menopausal women (p = 0.0001). However, the use of HRT in post-menopausal women was not associated with higher incidence of HDM (18.6%, n=110/592) compared to post-menopausal women without HRT (15.4%, n=211/1370) (p=n.s). Mammographic abnormality was more likely to occur in post-menopausal women without HRT (52%, n=711/1370) compared with women on HRT (38.7% n=229/592) (p = 0.0001). This held true for solid lump (p=0.0001), tissue irregularity (p=0.016) and calcifications (p=0.0005). Menopause was associated with higher likelihood (48%) of any mammographic finding compared with 41.6% in pre-menopausal women (p = 0.0017). A total of 266 women with mammographic findings prompting histological assessment were identified, revealing 105 malignant lesions. HRT in post-menopausal women was associated with lower incidence (28%) of malignancy compared to post-menopausal women without HRT (50%). CONCLUSIONS: The present study, portraying the inter-relationship between mammographic breast density, any abnormal finding in screening mammograms, and the use of HRT has not found such treatment to be associated neither with increased density, nor with higher probability of finding malignancy. Furthermore, a lower incidence of mammographic abnormality was noted in HRT users. Albeit, further and larger studies are required to substantiate these findings. The results of this study do not support the notion that HRT increases the likelihood of malignancy or affects breast density.

Diagnostic Value of Serum Bilirubin and Liver Enzyme Levels in Acute Appendicitis.

BACKGROUND: Acute appendicitis (AA) is one of the most common indications for emergency abdominal surgery. OBJECTIVES: To assess the diagnostic and prognostic value of serum bilirubin and liver enzyme levels in the management of acute appendicitis. METHODS: Consecutive emergency department patients referred for a surgical consult for suspected AA were prospectively enrolled in the study. Data regarding demographic, clinical and laboratory results were recorded. Receiver operating characteristic (ROC) curve was performed for all evaluated parameters. Clinical and laboratory markers were evaluated for diagnostic accuracy and correlation to the clinical severity, histology reports, and length of hospital stay. RESULTS: The study was comprised of 100 consecutive patients. ROC curve analysis revealed white blood cell count, absolute neutrophils count (ANC), C-reactive protein, total-bilirubin and direct-bilirubin levels as significant factors for diagnosis of AA. The combination of serum bilirubin levels, alanine transaminase levels, and ANC yielded the highest area under the curve (0.898, 95% confidence interval 0.835-0.962, P<0.001) with a diagnostic accuracy of 86%. In addition, total and direct bilirubin levels significantly correlated with the severity of appendicitis as described in the operative and pathology reports (P < 0.01). Total and direct bilirubin also significantly correlated with the length of hospital stay (P < 0.01). CONCLUSIONS: Serum bilirubin levels, alone or combined with other markers, may be considered as a clinical marker for AA correlating with disease existence, severity, and length of hospital stay. These findings support the routine use of serum bilirubin levels in the workup of patients with suspected AA.

Laparoscopic Lymph Node Biopsy: Efficacy and Advantages.

BACKGROUND: Diagnosis of abdominal lymphadenopathy is challenging when not accompanied by peripheral lymphadenopathy. Computed tomography-guided core-needle biopsy has largely replaced open procedures in recent years, but this approach is limited by access to the anatomic region and the amount of tissue acquired. OBJECTIVES: To demonstrate the feasibility of the laparoscopic approach in obtaining abdominal lymph node biopsies and to evaluate the diagnostic adequacy of the technique. METHODS: We reviewed the data of patients who underwent laparoscopic lymph node biopsy between 2014 and 2014 in our department. Demographics, intra-operative parameters and postoperative course were examined, as were histological reports. Postoperative complications were categorized according to the Clavien-Dindo(CD) classification. RESULTS: Between 2004 and 2014, 57 laparoscopic biopsies were performed for intra-abdominal lymphadenopathy. One case was a repeated attempt due to limited histologic material. The mean age was 49.5 ± 19.6 years. There were two conversions to open laparotomy, one due to small bowel injury and the other due to a sizable mass. Overall, 56 cases had full clinical data: 48 cases (85.7%) had CD=0, six (10.7%) had CD=1, one postoperative severe complication (CD=3) and one mortality (CD=5), which was related to preexisting hepatic insufficiency. Mean hospital stay was 1.6 days. Overall, adequate tissue samples were acquired in 96.7% and only 3 of these cases resulted in inconclusive diagnoses. CONCLUSIONS: Laparoscopic lymph node biopsy is a viable alternative to the currently available methods of tissue retrieval. It provides an access for nodes which are inaccessible percutaneously, and may allow a superior diagnostic yield.

Neo-adjuvant doxorubicin and cyclophosphamide followed by paclitaxel in triple-negative breast cancer among BRCA1 mutation carriers and non-carriers.

The purpose of this study was to assess pathological complete response and whether it serves a surrogate for survival among patients receiving neo-adjuvant doxorubicin-cyclophosphamide followed by paclitaxel for triple-negative breast cancer with respect to BRCA1 mutation status. From a neo-adjuvant systemic therapy database of 588 breast cancer cases, 80 triple-negative cases who had undergone BRCA genotyping were identified. Logistic regression model was fitted to examine the association between BRCA1 status and pathological complete response. Survival outcomes were evaluated using Kaplan-Meier method, differences between study groups calculated by log-rank test. Thirty-four BRCA1 carriers and 43 non-carriers were identified. The BRCA1 carriers had pathological complete response rate of 68 % compared with 37 % among non-carriers, p = 0.01. Yet this did not translate into superior survival for BRCA1 carriers compared with non-carriers. No difference in relapse-free survival were noted among those with or without pathological complete response in BRCA1 carriers regardless of pathological complete response status (Log-rank p = 0.25), whereas in the non-carrier cohort, relapse-free survival was superior for those achieving pathological complete response (Log-rank p < 0.0001). Response to neo-adjuvant systemic therapy differed in BRCA1-associated triple-negative breast cancer compared with triple-negative non-carriers, with a higher rate of pathological complete response. However, compared with non-carrier triple-negative breast cancer, pathological complete response was not a surrogate for superior relapse-free survival in BRCA1 patients. Future studies using specific chemotherapy regimens may provide further improvements in outcomes.

Mammographic Breast Density as a Predictor of Radiological Findings Requiring Further Investigation.

BACKGROUND: High density breast mammography has been associated with a greater risk for breast cancer and an increased likelihood of false negative results. OBJECTIVES: To assess whether the degree of mammographic breast density correlates with increased risk for the presence of radiographic findings requiring further histological investigation. METHODS: Included in the study were 2760 consecutive screening mammograms performed in a large volume, early detection mammography unit. All mammograms were complemented by high resolution ultrasound and interpreted by a single expert radiologist. Breast density (BD) was evaluated using a semi-quantitative 5 grade scale and grouped into low breast density (LBD) and high breast density (HBD) mammograms. Demographic and all relevant obstetric, personal and family history of breast cancer data were recorded. RESULTS: Of the 2760 mammograms 2096 (76%) were LBD and 664 (24%) were HBD. Mean age of the LBD and HBD groups was 59 ± 10.5 and 50.9 ± 9.3 years respectively (P = 0001). Breast density significantly correlated with presence of mammographic findings requiring further histological assessment (8.7% and 12.3% for LBD and HBD respectively, P < 0.01). In women younger than 60 years in whom histological assessment was required due to these findings, malignant pathology was significantly more prevalent in the HBD group (2.3% and 4.1% respectively, P = 0.03). Age, parity, patient history and HBD were identified as independent risk factors for any pathological mammographic finding. CONCLUSIONS: Highly dense mammography, aside from being an indicator of higher risk for breast cancer, appears to be associated with a significantly higher incidence of findings that will prompt further investigation to achieve a definite diagnosis.

Laparoscopic resection of rectal cancer.

BACKGROUND: The treatment of rectal cancer has changed significantly over the last few decades. Advanced surgicil techniques have led to an increase in the rate of sphincter-preserving operations, even for low rectal tumors. This was facilitated by preoperative oncologic treatment and the use of chemoradiation to downstage the tumor before resection. The introduction of total mesorectal excision further improved the oncologic outcome and became the standard of care. The use of laparoscopy for rectal resection is the most recent addition to this series of improvements, but in contrast to the use of laparoscopy in colon cancer its role is not yet well defined. OBJECTIVES: To present our experience with laparoscopic surgery for upper and lower rectal tumors. METHODS: A database was used to prospectively collect all data on laparoscopic rectal surgery in our department since we started performing these procedures in 1997. Follow-up data were collected from outpatient clinic visits, oncology files and telephone interviews. Updated survival data were retrieved from the national census. RESULTS: Of 750 laparoscopic colorectal procedures performed over a 13 year period, 67 were for rectal cancer. Of these, 29 were resections for tumors in the upper rectum (11-15 cm from the analverge) and 38 for tumors at 10 cm or below. Surgery was performed in 24 patients after neoadjuvant chemoradiation. There were 54 sphincter-preserving operations and 13 abdominoperineal resections. The mean operative time was 283 minutes. Conversion to an open procedure was required in 22% of the cases. Anastomotic leaks occurred in 17% of cases. Postoperative mortality was 4.5%. Long-term follow-up was available for 77% of the group, for a mean period of 42 months. Local recurrence was diagnosed in 4.5% of the patients and overall 5 year survival was 68%. CONCLUSIONS: Laparoscopic rectal resection is a demanding procedure. However, laparoscopy may become the preferred approach since it is a minimally invasive procedure and has an acceptable oncologic outcome that is comparable to that with the open approach. This conclusion, however, needs further validation.

The combined laparoscopic approach for the treatment of incarcerated inguinal hernia.

BACKGROUND: The traditional open approach to incarcerated inguinal hernia has several drawbacks including difficulty avoiding tension in the swollen and edematous tissues leading to a higher recurrence rate, possible contamination of the mesh if it is implanted in an area of bowel strangulation, and proper evaluation of whether ischemic bowel requires resection or not, which may mandate laparotomy. This study aimed to evaluate an approach that combines intraperitoneal laparoscopic exploration with hernia reduction and total extraperitoneal (TEP) repair of the hernia. METHODS: An exploratory laparoscopy is performed. The incarcerated content is gently retracted into the abdominal cavity and inspected. If no resection is needed, the gas is deflated, the umbilical trocar is removed, and the preperitoneal space is accessed with a Hasson trocar inserted behind the rectus muscle toward the pelvis. Two additional 5-mm trocars are inserted into the preperitoneal space in the lower midline. A standard TEP repair with mesh is performed. RESULTS: Between 2005 and 2008, 15 patients underwent laparoscopic exploration for incarcerated inguinal hernia followed by TEP repair. Of the 15 patients, 8 had acute incarceration and 7 had chronic irreducible hernia. Reduction of the incarcerated content was straightforward, and no bowel resection was needed. No major complications or wound or mesh infections occurred. CONCLUSION: The combined laparoscopic approach offers a solution to incarceration of inguinal hernias while taking advantage of each separate approach. The first part of the procedure enables easy reduction of the incarcerated content and assessment of its viability. The second part enables a simple and standard repair, similar to that for an elective case. If bowel necrosis is suspected preoperatively, an open anterior approach should be taken to avoid possible intraabdominal contamination.

Laparoscopic colectomy is associated with decreased postoperative gastrointestinal dysfunction.

BACKGROUND: Major abdominal surgery is associated with early postoperative gastrointestinal dysfunction, which may lead to abdominal distention and vomiting, requiring nasogastric (NGT) tube insertion. This study aimed to compare the rates of early postoperative NGT insertion after open and laparoscopic colorectal surgery. METHODS: A retrospective chart review was performed for patients who underwent colorectal surgery with removal of the NGT at completion of surgery. Patients who required reinsertion of the NGT in the early postoperative course were identified. The reinsertion rate for patients who underwent laparoscopic surgery was compared with that for the open group. RESULTS: There were 103 patients in the open group and 227 in the laparoscopic group. In the laparoscopic group, 42 patients underwent conversion to open surgery. Reinsertion of the NGT was required for 18.4% of the patients in the open group, compared with 8.6% of the patients for whom the procedure was completed laparoscopically (p = 0.02). Conversion to open surgery resulted in a reinsertion rate of 17%. CONCLUSION: Laparoscopic colorectal surgery is associated with decreased postoperative gastrointestinal dysfunction, resulting in a significantly lower NGT reinsertion rate.

Laparoscopic subtotal gastrectomy for gastric cancer.

BACKGROUND: The use of laparoscopy in the treatment of gastric malignancy is still controversial. However, several reports suggest that the laparoscopic approach may be safe and applicable. The aim of this study was to review our experience with laparoscopic gastrectomy for gastric malignant tumors amenable to subtotal gastrectomy, and assess the oncologic outcome. METHODS: The laparoscopic approach to subtotal gastrectomy was selected according to both the surgeon's and patient's preference. Data regarding demographics, operative procedures, postoperative course, and follow-up were prospectively collected in a computerized database. Survival data were obtained from the national census. RESULTS: Twenty patients were operated on, 18 for gastric adenocarcinoma, one for gastric lymphoma, and one for gastrointestinal stromal tumor. There were 10 males and 10 females, mean age of 67. D1 subtotal gastrectomy with Billroth-2 reconstruction was performed. Mean operative time was 335 minutes. Tumor-free margins were obtained in all cases, and a mean of 15 lymph nodes were retrieved. Median postoperative hospital stay was 12 days. Postoperative complications included leak from the duodenal stump (2), intraabdominal abscess (2), anastomotic leak (1), wound infection (1), and bowel obstruction (1); re-operation was required in 4 patients. No perioperative mortality occurred in our series. Pathology showed nodal involvement in 8 patients. During a mean follow-up of 39 months, 4 patients expired from recurrent and metastatic disease; all had positive lymph nodes. The Kaplan-Meier calculated 5-year survival was 79%. CONCLUSION: Although a challenging and lengthy procedure, laparoscopic subtotal gastrectomy yields acceptable surgical and oncologic results that may further improve with increased surgeon experience. Thus, the application of laparoscopy in the surgical treatment of distal gastric malignancy may be considered; however, further data are needed before this approach can be recommended.

High efficacy of pre-operative trastuzumab combined with paclitaxel following doxorubicin & cyclophosphamide in operable breast cancer.

BACKGROUND: Trastuzumab in combination with adjuvant chemotherapy improves disease free survival and overall survival in HER2 over-expressing breast cancer patients. Data concerning the use of trastuzumab in the neo-adjuvant setting is limited. We aimed to compare outcome of HER2 over-expressing breast cancer patients treated with either standard chemotherapy, consisting of doxorubicin, cyclophosphamide and a taxane to outcome of patients treated with the same chemotherapy regimen with the addition of trastuzumab in concurrence with paclitaxel. METHODS: We conducted a retrospective review of all consecutive HER2 over-expressing breast cancer patients treated at the participating institutions during the study period and received neo-adjuvant therapy. Allocation to trastuzumab was not based on clinical parameters and was approved only by part of the insurers. Clinical and pathological characteristics, as well as response rate and type of surgery were analyzed. RESULTS: Thirty seven patients received chemotherapy alone and 24 patients received chemotherapy and trastuzumab. A similar distribution of age, clinical stage and histology was noted in both groups. The rate of pathological complete response (pCR) was significantly higher among the trastuzumab-treated group compared to chemotherapy-alone group (75 vs. 24% respectively, p=0.0002). pCR in the breast was noted in 18 of 24 (75%) compared to 10 of 36 (28%, p=0.0005) and pCR in the axillary lymph nodes was noted in 19 of 20 (95%) compared to 8 of 28 (29%, p=0.0001), in the trastuzumab group compared to the chemotherapy-alone group respectively. The safety profile was similar between both groups and no clinical cardiotoxicity were noted. CONCLUSIONS: The addition of trastuzumab to standard chemotherapy in the neo-adjuvant setting improves pathological complete response rates in HER2 over-expressing breast cancer patients.

Low incidence of adhesion-related bowel obstruction after laparoscopic colorectal surgery.

BACKGROUND: Postoperative adhesions are a major cause of morbidity, accounting for approximately 5% of the readmissions of surgical patients. Bowel obstruction is attributed to adhesions in more than half of the cases, many of which are following colon and rectal surgery. Laparoscopic surgery has the potential advantage of reduced adhesion formation owing to attenuated surgical trauma, less tissue handling, and smaller scars. However, the translation of these advantages to a reduced rate of bowel obstruction has not been sufficiently demonstrated. The aim of this study was to assess the rate of adhesion-related bowel obstruction after laparoscopic colon and rectal surgery. METHODS: Data regarding all cases of laparoscopic colon and rectal surgery were prospectively collected. Information relative to demographics, surgical procedures, and follow-up was analyzed, and patients who were readmitted for bowel obstruction were identified. RESULTS: Over a period of 8 years, 306 patients, at a mean age of 63 years, had a laparoscopic colon and rectal operation in our department-122 for benign conditions and 184 for malignant disease. The mean length of follow-up was 38 months. Six cases (2%) of bowel obstruction, which were unrelated to hernia or advanced cancer, were identified. Two patients had a history of open surgery, in addition to the laparoscopic procedure, so adhesions could be attributed solely to the laparoscopic procedure in 4 patients, which consisted of 1.3% of the total study group. Obstruction occurred within 2 weeks of surgery in 2 patients, and one early reoperation was required. CONCLUSIONS: The incidence of adhesion ileus after laparoscopic colon and rectal surgery appears to be very low. This long-term benefit of laparoscopic surgery should be considered when comparing this technique to its open counterpart.

[Laparoscopic colon and rectal surgery--after ten years and 350 operations].

BACKGROUND: Within a decade since laparoscopy was used in cholecystectomy it has become the preferred approach in many abdominal procedures. Laparoscopic colon and rectal surgery has not yet been adopted by the majority of surgeons, due to technical complexity and reservation regarding its oncological safety. As data and experience accumulate, this attitude is gradually changing. We present our experience with laparoscopic surgery of the large bowel over the last ten years. AIM: To assess the short and intermediate term results after laparoscopic colon and rectal surgery, and to summarize the long term results after curative colectomy for malignancy. METHODS: Data regarding all patients undergoing laparoscopic colon and rectal surgery was prospectively entered into a computerized database, including demographics, surgical technique and perioperative course. Follow-up information was gathered at outpatient clinic visits, and using telephone interviews in selected cases. Data analysis was performed using a statistical software package. RESULTS: Over a period of ten years, 350 various laparoscopic colon and rectal procedures were performed, for both benign and malignant conditions. Sixty percent of the operations were for treatment of colorectal cancer. In 14.5% of cases conversion to open laparotomy was required. Post-operative complications included surgical site infection in 17.4%, anastomotic leak in 6.9%, and a mortality rate of 2.8%. Long term follow-up revealed cancer recurrence locally in 2.3% and systemically in 8.2%. Five year survival was 56% after resection of colorectal cancer regardless of the stage, and 63% after resection with curative intent. CONCLUSIONS: The laparoscopic approach to large bowel surgery enables short and long term results comparable with those achieved by open technique, regarding perioperative complication rate and long term oncologic outcome. The advantages of laparoscopy, related to reduced abdominal wall trauma, justify the adoption of this technique as a legitimate alternative to the open approach.

Perioperative COX-2 and ß-Adrenergic Blockade Improves Metastatic Biomarkers in Breast Cancer Patients in a Phase-II Randomized Trial.

Purpose: Translational studies suggest that excess perioperative release of catecholamines and prostaglandins may facilitate metastasis and reduce disease-free survival. This trial tested the combined perioperative blockade of these pathways in breast cancer patients.Experimental Design: In a randomized placebo-controlled biomarker trial, 38 early-stage breast cancer patients received 11 days of perioperative treatment with a ß-adrenergic antagonist (propranolol) and a COX-2 inhibitor (etodolac), beginning 5 days before surgery. Excised tumors and sequential blood samples were assessed for prometastatic biomarkers.Results: Drugs were well tolerated with adverse event rates comparable with placebo. Transcriptome profiling of the primary tumor tested a priori hypotheses and indicated that drug treatment significantly (i) decreased epithelial-to-mesenchymal transition, (ii) reduced activity of prometastatic/proinflammatory transcription factors (GATA-1, GATA-2, early-growth-response-3/EGR3, signal transducer and activator of transcription-3/STAT-3), and (iii) decreased tumor-infiltrating monocytes while increasing tumor-infiltrating B cells. Drug treatment also significantly abrogated presurgical increases in serum IL6 and C-reactive protein levels, abrogated perioperative declines in stimulated IL12 and IFNγ production, abrogated postoperative mobilization of CD16- "classical" monocytes, and enhanced expression of CD11a on circulating natural killer cells.Conclusions: Perioperative inhibition of COX-2 and ß-adrenergic signaling provides a safe and effective strategy for inhibiting multiple cellular and molecular pathways related to metastasis and disease recurrence in early-stage breast cancer. Clin Cancer Res; 23(16); 4651-61. ©2017 AACR.

Elevations of serum CA-125 predict severity of acute appendicitis in males.

BACKGROUND: Acute appendicitis (AA) is a common indication for urgent abdominal surgery. CA-125 glycoprotein antigen is a non-specific marker for epithelial ovarian cancer; CA-125 serum levels also increased in the conditions of peritoneal inflammation. The aim of this study was to examine the correlation between serum CA-125 levels and AA. METHODS: All emergency department (ED) patients with suspected AA were prospectively enrolled in the study. The serum level of CA-125 was checked in every patient on arrival to the ED in addition to the routine clinical and laboratory evaluation. Data regarding demographic, clinical, radiological, operative and pathological features were analysed. RESULTS: One hundred consecutive patients (48 males) were enrolled in the study. We found a statistically significant correlation between CA-125 levels in males and the severity of appendicitis as described in the operative and pathology reports (P = 0.008 and P = 0.02, respectively). In addition, we observed a trend towards higher levels of CA-125 in males with AA compared with males without AA (9.9 ± 4.7 versus 7.8 ± 3.2 U/mL, respectively; P = 0.09). CONCLUSIONS: CA-125 levels correlate with the severity of appendicitis in males and may serve as a surrogate marker for the severity of other intra-abdominal surgical diseases.

Teaching Laparoscopic Adrenalectomy to Surgical Residents.

INTRODUCTION: Laparoscopic adrenalectomy is the surgical treatment for various adrenal diseases. The procedure is a common surgical practice for urologists and general surgeons and requires fundamental laparoscopic skills, nowadays common in the surgical education of residents in these practices. The aim of this study is to assess whether laparoscopic adrenalectomy differs in outcome between certified and trained surgeons and surgical residents and whether the learning curve changes the endpoint of the surgery. MATERIALS AND METHODS: A cohort retrospective study, including all adult patients who underwent laparoscopic adrenalectomy between June 2008 and June 2014, was conducted. Patients' demographic, clinical, and surgical data were recorded and analyzed. RESULTS: Fifty-three patients were included in the database (21 men, 32 women) with a mean age of 54 years (range 17-77). The cause for surgery was most commonly a benign adrenal tumor (27 patients, 50.9%) followed by large nonfunctioning adrenal tumors (16 patients, 30.1%), and adrenal cancer (8 patients, 15%). Eighteen patients (33.9%) were operated by residents (4-6 years into the residency) and 35 patients by a certified senior surgeon (66.1%). Left-sided adrenalectomy was preferred to right-sided adrenalectomy for resident tutoring (P = .03). Overall, intraoperative complications were seen in 6 patients (11.3%) and postoperative complications were seen in 9 patients (16.9%). There were no differences in operation time (P = .36), intraoperative complications (P = .76), postoperative complications (P = .96), and length of stay (P = .34) between the patients operated by senior residents and certified surgeons. CONCLUSION: Laparoscopic adrenalectomy is a complex surgical procedure that should be a part of the surgical training of surgery residents, as it is safe in guided hands.

Late regeneration of infarcted small bowel mucosa: a case report.

Ischemic injury of the small bowel may recover after revascularization, provided that full-thickness infarction did not occur. Animal studies showed that if the mucosal crypts remain viable, rapid mucosal restitution occurs hours after injury. The treatment of transmucosal infarction that does not extend to full wall thickness, however, was not investigated thoroughly. The patient presented had a mesenteric event leading to resection of about half of his small bowel. The unresected segment had severe ischemic injury, which seemed to cause transmucosal, but not transmural, infarction. Imaging of the remaining small bowel revealed a seromuscular layer denuded of mucosa. The ischemic damage was too deep to allow rapid regeneration, and the patient had short-bowel syndrome. A year later, during operation for stricture complications, new mucosa covered parts of the small-bowel surface, encouraging the surgeon to elect a conservative approach. Sixteen months after the injury, normal mucosa covered the entire small bowel, and enteral feeding resumed successfully. This report shows that infarcted small-bowel mucosa may regenerate even months after injury.

Social and utilitarian considerations for allocating organs within a national organ sharing system: a computerized simulation model for policy decision-making.

BACKGROUND: An organ-sharing system should achieve fairness and optimal graft longevity. Balancing between social and utilitarian considerations is a sensitive ethical, public and medical issue that requires a means to examine the consequences of any allocation policy or planned changes thereof. OBJECTIVE: To evaluate the performance and applicability of a computerized simulation model by examining the impact of two opposing organ allocation policies (social or utilitarian) on predicted organ distribution regarding age, waiting time, recipient sensitization measured by panel reactive antibody level, and overall donor-recipient tissue matching (measured by the number of HLA antigen mismatches). METHODS: Using a computerized simulation model, virtual donors and recipients were emulated and organs were allocated according to either social algorithms or utilitarian policies. The resulting number of HLA mismatches, PRA, age, and waiting time distributions were compared between allocation strategies. RESULTS: Simulating allocation of 7,000 organs to 17,000 candidate recipients and implementing social policies yielded donor-recipient compatibility comparable to utilitarian policies (0-1 mm: 19.4% vs. 28%) while allocating 66.7% of organs to long waiters (>48 months). CONCLUSION: This computerized simulation model is a valuable tool for decision-makers establishing or modifying organ allocation policies.

Focused, minimally invasive radio-guided parathyroidectomy: a feasible and safe option for elderly patients with primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism in elderly patients is usually associated with additional co-morbidity that increases operative risk, and thus many geriatric patients are denied the benefit of surgery for a single parathyroid adenoma. OBJECTIVES: To evaluate the safety and efficacy of accurate single photon emission computed tomography sestamibi scintigraphy, enabling precise localization of a single adenoma, in the geriatric population. METHODS: Twenty-two patients aged 70 years and over with biochemically proven PHPT and with a single parathyroid adenoma identified by localization studies (sestamibi SPECT scan and ultrasonography) underwent 23 operations over 29 months (out of a total of 140 patients operated upon during the same period). Immediate preoperative sestamibi scintigraphy and marking of focal adenoma uptake followed by intraoperative hand-held gamma probe were used for the removal of the parathyroid adenoma by unilateral minimal access surgery. Associated major co-morbid conditions and pre- and postoperative calcium, phosphorus and parathormone levels were recorded. Indications for surgery were listed and operative and postoperative complications were noted. The patients were followed for a mean period of 17.7 months using the same parameters. RESULTS: The 22 patients with PHPT had a mean age of 76.3 +/- 5.9 years (range 70-88 years) and a female to male ratio of 13:9. Associated co-morbidity included ischemic heart disease (n = 15), hypertension (n = 22), non-insulin-dependent diabetes mellitus (n = 9), chronic obstructive pulmonary disease (n = 3), and previous neck surgery (n = 3). Mean preoperative serum calcium, phosphorous and PTH were 11.7 +/- 1.3 mg/dl, 2.5 +/- 0.5 mg/dl and 160.9 +/- 75.4 pg/ml respectively. In 20 of the 22 patients, surgery was successful in curing PHPT (91%). One patient had persistent hypercalcemia due to a missed adenoma, and repeat operation (by focused minimal accesss surgery) was successfully performed 2 weeks later. There were no complications and no morbidity postoperatively. Mean postoperative serum calcium, phosphorous and PTH were 9.6 +/- 1.2 mg/dl, 3.0 +/- 0.5 mg/dl and 35.2 +/- 24 pg/ml respectively. In all patients, serum calcium levels remained normal (9.7 +/- 1.3 mg/ml) after long-term follow-up (mean 17.7 +/- 9.6 months). CONCLUSIONS: Minimally invasive, radio-guided focused parathyroidectomy for a single adenoma is a safe and effective method to cure hyperparathyroidism in the elderly. Success of surgery is directly related to the surgeon's experience and to the precise localization marking provided by sestamibi scintigraphic SPECT localization and concurrent sonographic findings.

Detrimental effects of cyclosporin A on long-term graft survival in familial Mediterranean fever renal allograft recipients: experience of two transplantation centers.

BACKGROUND: Cyclosporin A has been associated with severe toxic side effects in patients with familial Mediterranean fever who underwent renal transplantation. Nevertheless, the impact on graft function and survival is not well documented. OBJECTIVE: To compare long-term graft function and survival, between CsA-based vs. CsA free immunosuppressive protocols in FMF recipients of renal allograft. METHODS: Data of FMF recipients were analyzed retrospectively. Graft survival and function and the incidence of acute rejection were correlated to graft source (living donor vs. cadaveric donor), colchicine dose, presence of proteinuria, and immunosuppression protocol (CsA-based triple drug therapy vs. azathioprine-prednisone alone). RESULTS: There were 35 FMF patients with primary renal grafts (13 from living donors and 22 from cadaveric donors). Mean follow-up was 10.6 +/- 6.05 years. Sixteen patients were on CsA-based triple drug therapy and 19 patients on AZA-Pred alone. Mean overall graft survival was 11.2 +/- 0.6 years and 9.4 +/- 1.36 vs. 11.6 +/- 0.4 years for CsA-treated and AZA-Pred groups respectively (P = 0.05). One-year survival was 94% and 96.6% for CsA-treated vs. non-CsA patients (not significant), but 5 and 10 years survival were 76% and 46%, compared to 94.5% and 86% respectively (P = 0.05 at 5 years and 0.001 at 10 years). Mean serum creatinine at time of data collection was 2.3 +/- 1.5 mg/dl in the CsA group vs. 1.6 +/- 0.7 mg/dl in the AZA-Pred group (P = 0.02). There were 14 and 13 reversible rejection episodes in the AZA-Pred and CsA groups respectively (not significant). CONCLUSION: It is suggested that CsA exerts detrimental effects on long-term renal graft function and survival in FMF patients.