Totally laparoscopic versus laparoscopic-assisted left colectomy for cancer: a retrospective review.

BACKGROUND: Laparoscopic left colectomy (LLC) became the standard of care for treating distal transverse and descending colon cancer in many centers. Most centers use laparoscopic-assisted colectomy with extracorporeal anastomosis (LAC/EA). A totally laparoscopic colectomy with intracorporeal anastomosis (TLC/IA) has been proposed. The purpose of our study is to compare these two techniques. METHODS: A series of 52 patients undergoing LLC for left-sided colon cancer was retrospectively evaluated. Thirty-three patients underwent TLC/IA, and 19 underwent LAC/EA. The following data were collected: gender, age, body mass index, American Society of Anesthesiologists risk class, operation duration, conversion to laparotomy, intraoperative complications, postoperative complications, postoperative course (duration of stay, time to first flatus), number of excised lymph nodes, readmission, and reoperation rates. Data were prospectively recorded in a colorectal cancer database and retrospectively analyzed. RESULTS: The only demographic parameter that differed significantly between the groups was age (64.2 ± 12.4 years for the TLC/IA group, vs. 72.7 ± 2.1 years for LAC/EA, p = 0.0116). The mini-laparotomy incision was significantly shorter in the TLC/IA than in the LAC/EA group (5.8 ± 0.9 vs. 8.2 ± 0.9 cm, respectively, p < 0.00001). Hospital stay duration was shorter in the TLC/IA group (4.2 ± 1.2 vs. 6.3 ± 1.9, p = 0.0001). The average number of harvested lymph nodes did not differ significantly between the groups (12.9 ± 5.7 in TLC/IA vs. 11.2 ± 4.2 in LAC/EA, p = 0.2546). No significant differences between the groups were observed in any other perioperative or surgical outcome parameters. CONCLUSIONS: TLC/IA in LLC for the treatment of left colon cancer is technically feasible and can be performed with a low complication rate, favorable cosmetics, and possibly shorter hospital stay, without significantly lengthening operative duration or compromising oncologic radicality principles. Although further prospective randomized studies are needed to determine its role and limitations, we encourage using it as an alternative to LAC/EA in LLC.

Laparoscopic adrenalectomy for malignant lesions: surgical principles to improve oncologic outcomes.

BACKGROUND: Laparoscopic adrenalectomy (LA) is the treatment of choice for benign adrenal lesions. Size of the lesion and radiologic features define the risk for malignancy. In lesions at high risk of malignancy, the experience with the laparoscopic approach is limited and therefore controversial. The purpose of this study was to determine the feasibility and oncological safety of LA for malignant disease. METHODS: Retrospective analysis of prospectively collected database. All LA performed in our department from 2003 to 2011 were reviewed and demographic, perioperative, and follow-up data for those who had malignancy in the final histological report was analyzed. Data are presented as mean ± standard deviation or median (range). RESULTS: Of 121 LA, we identified 20 patients with 21 malignant adrenal pathologies: 11 primary tumors, 5 adrenocortical carcinoma, 5 large B cell lymphoma, and 1 leiomyosarcoma. Ten metastatic lesions included 5 malignant melanoma (1 patient, both sides), 4 adenocarcinoma, and 1 renal cell carcinoma. There was no conversion to laparotomy. Tumor size was 4.5 (1-9.5) cm, operative duration was 79 (42-262) min, and estimated blood loss was 40 (0-250) ml. All patients resumed regular diet on postoperative day 1, and the median length of stay was 2 days after surgery. Two patients died at 6 and 24 months postoperatively. Three patients were lost to follow-up. All the rest of the patients were disease-free at a follow-up of 58 (7-96) months. CONCLUSIONS: LA for primary or metastatic malignant lesions is feasible and seems oncologically safe. Surgical principles should be the same for all LA: en bloc resection of all epinephric fat, minimal touch technique, and low threshold for conversion. Size of the lesion alone should not be an indication for open surgery.

Digital recording and documentation of endoscopic procedures: physicians' practice and perspectives.

BACKGROUND: In recent years, it has become increasingly prevalent internationally to record and archive digital recordings of endoscopic procedures. This emerging documentation tool raises weighty educational, ethical and legal issues - which are viewed as both deterrents and incentives to its adoption. We conducted a survey study aimed at evaluating the use of DRD in endoscopic procedures, to examine physicians' support of this practice and to map the considerations weighed by physicians when deciding whether or not to support a more extensive use of DRD. METHODS: Israeli physicians from specialties that employ endoscopic technics were surveyed anonymously for demographic background, existence and use of recording equipment, existence of institutional guidelines regarding DRD, and self-ranking (on a scale from 1 to 7) of personal attitudes regarding DRD. RESULTS: 322 physicians were surveyed. 84% reported performing routine endoscopic procedures, 78% had the required equipment for digital recording, and 64% of them stated that they never or only rarely actually recorded the procedure. General surgeons had the second highest rate of DRD equipment (96.5%) but the lowest rates of DRD practice (17.5%). The average ranking of support of DRD by all participants was 5.07 ± 1.9, indicating a moderately high level of support. Significant positive correlation exists between actual DRD rates and average support of DRD (p < 0.001). Based on mediation models, for all specialties and with no exceptions, having routine recording guidelines and positive support of DRD were found to increase the probability of actual recording. Being a surgeon or an urologist negatively correlated with support of DRD, and decreased actual recording rates. The argument "Recording might cause more lawsuits" was ranked significantly higher than all other arguments against DRD (p < 0.001), and "Recording could aid teaching of interns" was ranked higher than all other arguments in favor of DRD (p < 0.001). CONCLUSIONS: While DRD facilities and equipment are fairly widespread in Israel, the actual recording rate is generally low and varies among specialties. Having institutional guidelines requiring routine recording and a positive personal support of DRD correlated with actual DRD rates, with general surgeons being markedly less supportive of DRD and having the lowest actual recording rates. Physicians in all specialties were very much concerned about DRD's potential to enhance lawsuits, and this greatly influenced their use of DRD. These findings should be addressed by educational efforts, centering on professionals from reluctant specialties, as well as by the issuing of both professional and institutional guidelines endorsing DRD as well as requiring it where applicable.

Effect of transforming growth factor-alpha on enterocyte apoptosis is correlated with EGF receptor expression along the villus-crypt axis during methotrexate-induced intestinal mucositis in a rat.

The purpose of the present study was to evaluate the effect of transforming-growth factor-alpha (TGF-alpha) on enterocyte apoptosis following methotrexate (MTX) induced intestinal mucositis in a rat and in Caco-2 cells. Non-pretreated and pretreated with MTX Caco-2 cells were incubated with increasing concentrations of TGF-alpha. Cell apoptosis was determined by FACS cytometry. Adult rats were divided into four groups: Control, Control-TGF-alpha, MTX, and MTX- TGF-alpha rats. Three days later rats were sacrificed. Enterocyte apoptosis were measured at sacrifice. RT-PCR and Western Blotting was used to determine the level of Bax and Bcl-2 mRNA and protein. Real time PCR was used to measure epidermal growth factor receptor (EGFr) expression along the villus-crypt axis. The in vitro experiment has shown that treatment with TGF-alpha of Caco-2 cells results in a significant inhibition of cell apoptosis in a dose-dependent manner. In vivo experiment, a decreased levels of apoptosis in MTX- TGF-alpha rats corresponded with the decrease in Bax and with the increase in Bcl-2 at both mRNA and protein levels. The inhibiting effect of TGF-alpha on enterocyte apoptosis was strongly correlated with EGFr expression along the villus-crypt axis. In conclusion, treatment with TGF-alpha inhibits enterocyte apoptosis following MTX- injury in the rat.

What variables are associated with the public's willingness to take measures to maintain a hygienic hospital environment?

BACKGROUND: Most of the studies on hospital infections have focused on the perceptions and reported behavior of the medical personnel. This research explore the practices undertaken both by Israeli patients and visitors, in order to maintain a hygienic hospital environment, and to locate the variables that are associated with them. METHODS: An online survey of national representative sample of Israeli hospital's visitors and patients adult population, who were hospitalized in the five years before the interview (n=209), and who visited patients in hospitals in the three years before the interview (n=454). RESULTS: Only a minority of patients (24%) comment to medical personnel about maintaining hygiene, while a majority (67%-69%) took active steps to maintain a hygienic environment. The main variables that were found to be associated with patients' making comments were level of religiousness and gender, whereas priorities, namely whether hospital infections were a high priority, and the frequency of the patient's visits to hospital outpatient clinics, were associated with self-initiated action. CONCLUSIONS: In order to reduce barriers to commenting to hospital personnel, we propose framing the subject of hospital hygiene as a matter of health literacy and a subject of public discourse, rather than a sole medical issue.

Beyond the hospital infection control guidelines: a qualitative study using positive deviance to characterize gray areas and to achieve efficacy and clarity in the prevention of healthcare-associated infections.

Background: The literature is replete with attempts to design and promote customized guidelines to reduce infections during the care continuum. Paradoxically, these efforts sometimes result in gray areas where many staff members are unaware of what is required of them, which then leads to confusion, frustration, and uncertainty.We coined the phrase "gray areas" in this context to encompass the variety of situations on the care continuum that are not addressed in the accepted guidelines, and where staff members are unsure of how to proceed.The purpose of the present study was to characterize the gray areas that were reported by staff and to identify the practices of Positive Deviance (PD) individuals. We define to PD individuals as people who independently develop creative solutions to solve problems not identified by the majority in their community. Methods: A qualitative constructivist research methodology was used that included personal interviews, observations and video recordings of identified PD practices to enhance infection control. The study was conducted January through March 2018, in two Intensive Care Units (ICU) units at Hadassah Hospital, Jerusalem, Israel. Personal interviews were conducted with 82 staff members from the General ICU (GICU) and Medical ICU (MICU). Results: The study confirmed that guidelines cannot cover all the different situations that arise during the care continuum and can paradoxically result in the increased spread of hospital infections. Our study found there are numerous individuals who independently develop and implement solutions for gray areas. The creative and practical solutions of PD individuals can address the barriers and difficulties on the care continuum that were encountered by the staff in their communities. For example, inserting a central venous line is a complex practice in the general guidelines, while the PDs provided clear situation-specific solutions not covered in the guidelines. Conclusions: The recommendations of the present study are to encourage hospital personnel to create their own solutions for various situations on the care continuum, and to disseminate them within their units to achieve a bottom up change, in lieu of investing in new or specific written guidelines.

Digital Recording and Documentation of Endoscopic Procedures: Do Patients and Doctors Think Alike?

Aims and Methods. Conducting a survey study of a large number of patients and gastroenterologists aimed at identifying relevant predictors of interest in digital recording and documentation (DRD) of endoscopic procedures. Outpatients presenting to the endoscopy unit at our institution for an endoscopy examination were anonymously surveyed, regarding their views and opinions of a possible recording of the procedure. A parallel survey for gastroenterologists was conducted. Results. 417 patients and 62 gastroenterologists participated in two parallel surveys regarding DRD of endoscopic procedures. 66.4% of the patients expressed interest in digital documentation of their endoscopic procedure, with 90.5% of them requesting a copy. 43.6% of the physicians supported digital recording while 27.4% opposed it, with 48.4% opposing to making a copy of the recording available to the patient. No sociodemographic or background factors predicted patient's interest in DRD. 66% of the physicians reported having recording facilities in their institutions, but only 43.6% of them stated performing recording. Having institutional guidelines for DRD was found to be the only significant predictor for routine recording. Conclusions. Our study exposes patients' positive views of digital recording and documentation of endoscopic procedures. In contrast, physicians appear to be much more reluctant towards DRD and are centrally motivated by legal concerns when opposing DRD, as well as when supporting it.

Minimizing Hemorrhagic Complications in Laparoscopic Sleeve Gastrectomy--a Randomized Controlled Trial.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has gained worldwide popularity in recent years. Hemorrhagic complications (HC) are usually the result of stapler line bleeding and are probably underreported. The previous incidence of HC in our department including minor bleeding and late hematomas was 15.0 %. The objective of this study is to assess the impact of stapler line reinforcement (SLR) and intraoperative blood pressure control on HC after LSG. METHODS: Between February 2013 and March 2014, patients who were admitted to our department for LSG were randomly assigned to one of three arms: stapler line application of biologic glue--Evicel™ (E), over suture of the stapler line (S) or control (C). Surgical technique in all arms included blood pressure elevation to 140 mmHg before termination of the procedure. Data is presented as mean ± SD or median (IQR 25-75). RESULTS: One hundred sixty-five patients were randomized: 49 to E, 49 to S, and 67 to C. There were no demographic differences between arms. Operative time was significantly longer in S than in E and C arms (74 ± 21 vs. 64 ± 23 and 54 ± 19 min, respectively). ∆Hb was significantly lower in the S group. Packed cells were used in two from E and one from C arms. Late infected hematoma occurred in three (1.8 %) patients: one from E and two from C arms. Leak rate was 1.2 %: one from S and one from C arms. LOS was the same. No patients were re-operated due to bleeding. CONCLUSIONS: In this randomized trial, routine elevation of systolic blood pressure to 140 mmHg and over suture of the staple line in LSG minimized HC, with reasonable prolongation of the procedure.

Major respiratory adverse events after laparascopic gastric banding surgery for morbid obesity.

BACKGROUND: Laparoscopic adjustable gastric banding surgery has become one of the most common restrictive surgical procedures for treatment of morbid obesity worldwide. Although short-term respiratory complications are well known, long-term data is scarce. We investigated the manifestations of major pulmonary complications showed at least six months after the procedure. METHODS: A retrospective cohort study was conducted at a tertiary university medical center in the five years period of 2006-2010. We included every patient who had had major respiratory complication who needed hospitalization, at least 6 months after laparoscopic adjustable gastric banding procedure. Demographic, pre-operative and post-operative clinical data were collected. We documented respiratory symptoms, results of physical examination, pulmonary function tests, and imaging as well as therapies given and outcome. RESULTS: Out of 2100 patients who underwent LAGB, thirty subjects, mean age of 45.7 (range 29-64) with an equal number of males and females were included. Mean interval between operation and onset of respiratory symptoms was 51.5 months (range 10-150 months). All had dyspeptic complaints which included: regurgitation, fullness after meals, dysphagia and food aspiration with esophageal dilatation. Major respiratory complications included aspiration pneumonia (19) including pulmonary abscess (4) and empyema (2), exacerbation of asthma (3) and hemoptysis (1). Additionally we documented the emergence of chronic diseases such as interstitial lung disease (5) and bronchiectasis (3). One patient developed acute respiratory distress syndrome due to aspiration pneumonia and eventually died in the intensive care unit. The main mode of therapy was deflation of the gastric band. Those who refused to deflate or remove the gastric banding continued to suffer from dyspeptic and respiratory symptoms including recurrent pulmonary abscess. CONCLUSION: Although laparoscopic adjustable gastric banding surgery has few short-term risks and is highly effective at achieving weight reduction, we found an increased risk for major respiratory complications in the long-term period. The obesity epidemic and the increased use of surgical techniques to treat obesity will most likely lead to an increase in the incidence of long-term post-operative respiratory complications. This entity is probably under-reported and needs further research into how to reduce its incidence and morbidity.

Leptin accelerates enterocyte turnover during methotrexate-induced intestinal mucositis in a rat.

Gastrointestinal mucositis occurs as a consequence of cytotoxic treatment. In the present study, we tested whether leptin can protect gut epithelial cells from methotrexate (MTX)-induced intestinal damage. Non-pretreated and pretreated with MTX Caco-2 cells were incubated with increasing concentrations of leptin for 24 h. Cell proliferation and apoptosis were assessed using FACS analysis. Adult rats were divided into three experimental groups: Control rats; MTX-rats were treated with a single dose of MTX, and MTX-LEP rats were also treated with leptin for 3 d. Intestinal mucosal damage (Park score), mucosal structural changes (bowel and mucosal weight, mucosal DNA and protein content, villus height and crypt depth), enterocyte proliferation, and enterocyte apoptosis were measured at sacrifice. RT-PCR was used to determine the level of bax and bcl-2 mRNA expression. In the vitro experiment, treatment with leptin of Caco-2 cells pre-treated with MTX resulted in a significant stimulation of cell proliferation and inhibition of cell apoptosis in a dose-dependent manner. In the vivo experiment, MTX-LEP rats demonstrated a greater jejunal and ileal bowel and mucosal weight, mucosal DNA and protein, villus height and crypt depth, as well as a greater enterocyte proliferation index compared to MTX-animals. MTX-LEP rats also showed a trend toward an increase in enterocyte apoptosis that was accompanied by an increase in bax mRNA and decrease in bcl-2 mRNA expression. In conclusion, leptin enhances proliferation and decreases apoptosis in Caco-2 cells pretreated with MTX. In a rat model of MTX-induced mucositis, treatment with leptin improves intestinal recovery and enhances enterocyte turnover.

Transforming growth factor-alpha stimulates enterocyte proliferation and accelerates intestinal recovery following methotrexate-induced intestinal mucositis in a rat and a cell culture model.

PURPOSE: Recent evidence suggests that transforming growth factor-alpha (TGF-alpha) enhances enterocyte proliferation and exerts a gut trophic effect. The purpose of the present study was to evaluate the effect of TGF-alpha on enterocyte proliferation and intestinal recovery following methotrexate (MTX)-induced intestinal mucositis in rats and in Caco-2 cells. METHODS: Nonpretreated Caco-2 cells and those pretreated with MTX were incubated with increasing concentrations of TGF-alpha. Cell proliferation was determined by FACS cytometry. Adult rats were divided into three groups: control rats treated with vehicle, MTX rats treated with one dose (20 microg/kg) of MTX given intraperitoneally, and MTX-TGF-alpha rats treated with one dose of MTX followed by two doses of TGF-alpha (75 microg/kg a day). Three days after MTX injection, rats were sacrificed. Intestinal mucosal damage (Park's score), mucosal structural changes, and enterocyte proliferation were measured at sacrifice. Western blotting was used to determine the level of extracellular signal-related kinase (ERK) protein, a marker of cell proliferation. A nonparametric Kruskal-Wallis ANOVA test was used for statistical analysis with P value less than 0.05 considered statistically significant. RESULTS: The in vitro experiment demonstrated that treatment with TGF-alpha of Caco-2 cells resulted in a significant stimulation of cell proliferation in a dose-dependent manner. The in vivo experiment showed that treatment with TGF-alpha resulted in a significant increase in bowel and mucosal weight, DNA and protein content in jejunum and ileum, villus height in jejunum and ileum, crypt depth in ileum, and increased cell proliferation in jejunum and ileum compared to the MTX group. MTX-TGF-alpha rats also had a significantly lower intestinal injury score in ileum when compared to MTX animals. The increase in levels of cell proliferation in MTX-TGF-alpha rats corresponded with the increase in ERK protein levels in intestinal mucosa. CONCLUSION: Treatment with TGF-alpha prevents mucosal injury, enhances ERK-induced enterocyte proliferation, and improves intestinal recovery following MTX-induced intestinal mucositis in rats. These findings correlated with the observation that TGF-alpha also caused a significant stimulation of cell proliferation in a Caco-2 cell culture model treated with MTX. These observations may have significant implications for the treatment of patients on chemotherapy who develop severe mucositis.