[REGIONAL NODAL SURGERY IN THE MANAGEMENT OF BREAST CANCER].

INTRODUCTION: Management of the regional lymph nodes is an essential element of breast cancer care and has changed dramatically over the years. At its beginning in the last century, radical axillary lymph node dissection was the only type of surgery accepted. Due to the high and significant morbidity associated with the radical procedure, the magnitude of the dissection was decreased by omitting level III resection. Nevertheless, the morbidity was still significant. With the beginning of mass screening along with improvements in the understanding of the biology of the disease and improvements in medical treatments and radiotherapy, the importance of axillary lymph node dissection decreased together with the decrease in the number of patients needing this procedure for node-positive disease. This prompted the development of sentinel lymph node biopsy as a more selective approach for defining the nodal status and need for dissection. The accuracy of sentinel lymph node biopsy was validated, omitting the need for axillary dissection in node-negative women, leaving the need for dissection mainly for locally advanced disease and following primary medical treatment. However, in recent years some new large scale controlled studies have shed further information that may permit avoiding axillary dissection in some node-negative patients and following neoadjuvant therapy for node-positive patients. Here, we will review the history of regional lymph node surgery and the modern approach in breast cancer.

CT as a first-line modality in elderly patients with stable blunt chest trauma.

PURPOSE: Blunt thoracic injuries are common among elderly patients and may be a common cause of morbidity and death from blunt trauma injuries. We aimed to examine the impact of chest CT on the diagnosis and change of management plan in elderly patients with stable blunt chest trauma. We hypothesized that chest CT may play an important role in providing optimal management to this subgroup of trauma patients. METHODS: A retrospective analysis was performed on all the admitted adult blunt trauma patients between January 2014 and December 2018. Stable blunt chest trauma patients with abbreviated injury severity (AIS) < 3 for extra-thoracic injuries confirmed with chest X-ray (CXR) and chest CT on admission or during hospitalization were included in the study. The AIS is an international scale for grading the severity of anatomic injury following blunt trauma. Primary outcome variables were occult injuries, change in management, need for surgical procedures, missed injuries, readmission rate, intensive care unit (ICU) and length of hospital stay. RESULTS: There are 473 patients with blunt chest trauma included in the study. The study patients were divided into two groups according to the age range: group 1: 289 patients were included and aged 18-64 years; group 2: 184 patients were included and aged 65-99 years . Elderly patients in group 2 more often required ICU admission (11.4% vs. 5.2%), had a longer length of ICU stay (days) (median 11 vs. 6, p = 0.01), and the length of hospital stay (days) (median 14 vs. 6, p = 0.04). Injuries identified on chest CT has led to a change of management in 4.4% of young patients in group 1 and in 10.9% of elderly patients in group 2 with initially normal CXR. Chest CT resulted in a change of management in 12.8% of young patients in group 1 and in 25.7% of elderly patients in group 2 with initially abnormal CXR. CONCLUSION: Chest CT led to a change of management in a substantial proportion of elderly patients. Therefore, we recommend chest CT as a first-line imaging modality in patients aged over 65 years with isolated blunt chest trauma.

Surgical Management of the Breast and Axilla after Neoadjuvant Therapy.

The indications for the use of neoadjuvant chemotherapy (NAC) for the management of breast cancer have broadened immensely in recent years. Initially intended mostly for inoperable breast cancers, this modality has then became the standard of care for locally advanced cancers. This treatment allowed safe surgical margin resection and in many patients with large tumors it allowed breast conserving surgery, avoiding the need for mastectomy. As clinical experience with NAC has increased along with the introduction of novel medications and better understanding of tumor biology, the indications for its use have become even more common for the treatment of some subtypes of early breast cancer. Furthermore, the use of NAC was found to have an impact on decreasing the need for axillary lymph node dissection in selected patients presenting initially with positive lymph nodes. This article will review the current practice and indications of NAC in breast cancer as well as some controversial issues regarding the surgical management of the breast and the axilla following neoadjuvant treatment.

The emergency department length of stay: Is the time running out?

PURPOSE: To examine the relationships between emergency department length of stay (EDLOS) with hospital length of stay (HLOS) and clinical outcome in hemodynamically stable trauma patients. METHODS: Prospective data collected for 2 years from consecutive trauma patients admitted to the trauma resuscitation bay. Only stable blunt trauma patients with appropriate trauma triage criteria requiring trauma team activation were included in the study. EDLOS was determined short if patient spent less than 2 h in the emergency department (ER) and long for more than 2 h. RESULTS: A total of 248 patients were enrolled in the study. The mean total EDLOS was 125 min (range 78-180). Injury severity score (ISS) were significantly higher in the long EDLOS group (17 ± 13 versus 11 ± 9, p < 0.001). However, when leveled according to ISS, there were no differences in mean in diagnostic workup, admission rate to intensive care unit (ICU) or HLOS between the short and long EDLOS groups. CONCLUSION: EDLOS is not a significant parameter for HLOS in stable trauma patients.

Correction to: The mTOR inhibitor rapamycin down-regulates the expression of the ubiquitin ligase subunit Skp2 in breast cancer cells.

After the publication of this work [1], an error was noticed in Fig. 2b, Fig. 3a and Fig. 5b. The Skp1 loading control was accidentally duplicated. We apologize for this error, which did not affect any of the interpretations or conclusions of the article.

Outcome of Delayed Cholecystectomy after Percutaneous Cholecystostomy for Acute Cholecystitis.

BACKGROUND: Recent studies have suggested that urgent cholecystectomy is the preferred treatment for acute cholecystitis. However, initial conservative treatment followed by delayed elective surgery is still common practice in many medical centers. OBJECTIVES: To determine the effect of percutaneous cholecystostomy on surgical outcome in patients undergoing delayed elective cholecystectomy. METHODS: We conducted a retrospective analysis of all patients admitted to our medical center with acute cholecystitis who were treated by conservative treatment followed by delayed cholecystectomy between 2004 and 2013. Logistic regression was calculated to assess the association of percutaneous cholecystostomy with patient characteristics, planned surgical procedure, and the clinical and surgical outcomes. RESULTS: We identified 370 patients. Of these, 134 patients (36%) underwent cholecystostomy during the conservative treatment period. Patients who underwent cholecystostomy were older and at higher risk for surgery. Laparoscopic cholecystectomy was offered to 92% of all patients, yet assignment to the open surgical approach was more common in the cholecystostomy group (16% vs. 3%). Cholecystostomy was associated with significantly higher conversion rates to open approach (26% vs. 13%) but was not associated with longer operative time, hemorrhage, surgical infections, or bile duct or organ injuries. CONCLUSIONS: Treatment with cholecystostomy is associated with higher conversion rates but does not include other major operative-related complications or poorer clinical outcome.

Rivaroxaban-Induced Gastrointestinal Bleeding Presenting as Acute Colon Obstruction.

BACKGROUND: Rivaroxaban is a member of the novel target-specific oral anticoagulants (TSOACs) family of drugs recently approved for the prevention and treatment of venous thromboembolism events. A major drawback of the drug is its potential for causing severe hemorrhagic events, which may be difficult to treat in an emergency setting due to lack of effective antidote. Here, we describe a case of acute gastrointestinal (GI) hemorrhage leading to complete colon obstruction in a patient treated with rivaroxaban. Summary and Key Messages: The case presented here demonstrates a chain of events originating from an unprovoked intramural bleeding in a patient using rivaroxaban, leading to an organized giant clot formation, and to complete colon obstruction. In the available literature, the specific site of the GI bleeding has not been discussed. A further study is recommended and re-examination of bleeding events and exploration of new cases due to the use of TSOACs can help predict the course and the outcomes of such complications.

Adenocarcinoma of the Gallbladder: Incidental Finding in Patients following Laparoscopic Sleeve Gastrectomy and Cholecystectomy.

BACKGROUND: Gallbladder (GB) cancer is rare. Most cases are incidentally found in specimens after a cholecystectomy. Cholelithiasis is almost always present when this diagnosis is made. Obesity is a known risk factor for gallstone formation and thus may be related to GB cancer. OBJECTIVES: To highlight the importance of evaluating the gallbladder before surgery, resecting the gallbladder whenever required, and screening the resected tissue for malignancy. METHODS: We retrospectively searched a prospectively maintained database of all bariatric procedures during the last 8 years for cases of concomitant laparoscopic sleeve gastrectomy (LSG) and laparoscopic cholecystectomy (LC). Pathologic reports of the gallbladders were reviewed. Demographic data and perioperative parameters were documented. RESULTS: Of 2708 patients reviewed, 1721 (63.55%) were females and 987 (36.45%) males. Excluded were 145 (5.35%) who had a previous cholecystectomy. Of the remaining 2563, 180 (7.02%) had symptomatic gallbladder disease and underwent LSG with LC. Of these, two females (BMI 53 kg/m2 and 47 kg/m2, both age 60) were found by histological examination to have adenocarcinoma in their GB specimens (1.11%). Both were reoperated, which included partial hepatectomy of the GB bed, resection of the cystic stump, lymph node dissection, and resection of the port sites. One patient is doing well, with no evidence of disease at a postoperative follow-up of 4 years. The second patient had recurrent disease with peritoneal spread and ascites 20 months post-surgery and died 18 months later. CONCLUSIONS: GB cancer is a rare finding in cholecystectomy specimens. The incidence of this entity might be higher in obese older females owing to the higher incidence of cholelithiasis in these patients.

Advantages of minimal incision laparoscopic cholecystectomy.

BACKGROUND: Modifications to conventional laparoscopic cholecystectomy (CLC) are aimed at decreasing abdominal wall trauma and improving cosmetic outcome. Although single-incision laparoscopic surgery (SILS) provides excellent cosmetic results, the procedure is technically challenging and expensive compared to the conventional laparoscopic approach. OBJECTIVES: To describe a novel, hybrid technique combining SILS and conventional laparoscopy using minimal abdominal wall incisions. METHODS: Fifty patients diagnosed with symptomatic cholelithiasis were operated using two reusable 5 mm trocars inserted through a single 15 mm umbilical incision and a single 2-3 mm epigastric port. This technique was clubbed "minimal incision laparoscopic cholecystectomy" (MILC). RESULTS: MILC was completed in 49 patients (98%). In five patients an additional 3 mm trocar was used and in 2 patients the epigastric trocar was switched to a 5 mmtrocar. The procedure was converted to CLC in one patient. Mean operative time was 29 minutes (range 18-60) and the average postoperative hospital stay was 22 hours (range 6-50). There were no postoperative complications and the cosmetic results were rated excellent by the patients. CONCLUSIONS: MILC is an intuitive, easy-to-learn and reproducible technique and requires small changes from CLC. As such, MILC may be an attractive alternative, avoiding the cost and complexity drawbacks associated with SILS.

High rates of recurrence of gallstone associated episodes following acute cholecystitis during long term follow-up: a retrospective comparative study of patients who did not receive surgery.

INTRODUCTION: Patients who are admitted with acute cholecystitis (AC) and do not undergo urgent cholecystectomy, are usually referred for interval cholecystectomy. Many do not have surgery for various reasons, and some of those do not suffer from any recurrent symptoms. The primary objective of this study was to assess the rate and nature of recurrent gallstone-related events in this population over a long period, and its association with demographic and clinical parameters. A secondary objective was to assess the reasons for not undergoing surgery. METHODS: This is a retrospective cohort study, where the study group were adult patients admitted with AC. Patients that have suffered recurrent episodes were compared with those who did not. A control group of patients that had undergone cholecystectomy following an admission with AC was used for comparison. Demographic and clinical parameters were recorded for all patients, and the association with a recurrent episode was analyzed using univariate analysis. RESULTS: The study population was 197 patients. The group of patients who did not undergo surgery were significantly older (68.7 vs 54.2) and sicker (ASA > 3 50% vs 19%). The rate of recurrent episodes in the study group was 38.5%, and it was not found to be associated with the studied parameters. There was a trend towards higher gallstone disease specific mortality in the study group (5.5% vs 1.45% p = 0.062). CONCLUSIONS: This is a study of long-term follow-up of patients following an episode of AC we showed that the rate of recurrent episodes is quite high and involves severe inflammatory diseases, such as obstructive jaundice and pancreatitis.

Breast-conserving surgery and intraoperative electron radiotherapy in early breast cancer: experience at the Rambam Health Care Campus.

BACKGROUND: Local recurrences after breast-conserving surgery occur mostly at the site of the primary carcinoma. The main objective of postoperative radiotherapy is sterilization of residual cancer cells. Whole-breast radiotherapy is the standard of care, but its utility has recently been challenged in favor of radiotherapy limited to the area at highest risk of recurrence. Intraoperative electron radiotherapy (IOeRT) is an innovative technique for accelerated partial breast irradiation (APBI) that is applied to selected patients affected by early breast cancer. OBJECTIVES: To describe our experience with IOeRT at the Rambam Health Care Campus in Haifa since we began utilizing this modality in 2006. METHODS: From April 2006 to September 2010, 31 patients affected by unifocal invasive duct breast carcinoma < or = 2 cm diameter received wide local resection followed by intraoperative radiotherapy with electrons. Patients were evaluated for early and late complications, and other events, 1 month after surgery and every 3 months thereafter for the duration of the first 2 years. RESULTS: After a mean follow-up of 36 months, seven patients developed mild breast fibrosis and three suffered from mild postoperative infection. Rib fractures were observed in four patients before routine lead shielding was initiated. Additional whole-breast irradiation was given to four patients. None of the patients developed local recurrences or other ipsilateral cancers. Similarly, no contralateral cancers or distant metastases were observed. CONCLUSIONS: Intraoperative electron radiotherapy may be an alternative to external beam radiation therapy in an appropriate selected group of early-stage breast cancer patients. However, long-term results of clinical trials are required to better evaluate the indications and utility of this technique in the management of breast cancer.

Early Outcomes and Mid-Term Safety of One Anastomosis Gastric Bypass Are Comparable with Roux-en-Y Gastric Bypass: a Single Center Experience.

BACKGROUND: The use of one anastomosis gastric bypass (OAGB) has increased in recent years. However, the efficacy and safety outcomes of this procedure remain under debate. Here, we compare our early outcome and mid-term safety of OAGB with primary Roux-en-Y gastric bypass (RYGB). METHODS: This was a retrospective study using computerized electronic medical records data of patients who underwent RYGB or OAGB as a primary procedure from February 2012 to February 2019 in our bariatric center. Data collected included demographics, weight-outcomes, adverse events, hospital readmission, reoperation rates, and mortality following both procedures. RESULTS: A total of 314 patients were included (132 RYGB and 182 OAGB). Operative time and costs were significantly lower for OAGB (80 vs. 125 min, p<0.01 and 2018.8 vs. 2912.3 USD, p < 0.01, respectively), but length of hospital stay was longer (4.06 ± 0.67 days vs. 3.58 ± 0.79, p < 0.0001). At 12 months post-surgery, the percentage of excess body mass index loss was comparable between the two groups, but the change in body mass index (BMI) was significantly higher in the OAGB group. Early (< 30 days) and late (> 30 days) surgical adverse events were also similar between the two groups. CONCLUSION: Comparable short- and mid-term outcomes and adverse events are found for primary OAGB and RYGB. OAGB is not inferior to RYGB as a primary bariatric procedure for the treatment of obesity.

The Impact of Ethnic Differences Between Israeli-Jews and Israeli-Arabs on Post-bariatric Surgery Weight Loss: a Prospective Cohort Analysis.

Previous studies from different countries have shown that ethnic diversity may have an important effect on clinical outcome following bariatric procedures. Israel has an ethnic diverse population but there is limited information about this effect on surgery outcome. We carried out a 3-year institutional, prospective comparative data collection study among Jewish and Arab patients in Israel undergoing primary bariatric surgery. Percent of total weight loss (%TWL) and change in body mass index (BMI) were assessed. The results revealed no difference between Arab and Jewish participants in %TWL nor BMI change. Differences in absolute BMI values were all accounted for by the initial between-group difference in the pre-operative BMI. Comorbidity resolution at 1 year post-surgery was not significantly different between the groups.

Cyclin-dependent kinase inhibitor p27 as a prognostic biomarker and potential cancer therapeutic target.

The prognosis and clinical management of patients with cancer is commonly determined by traditional clinical and pathological factors. Nevertheless, patients may present with significantly different clinical outcomes despite similar clinicopathological features. This has prompted intense research to find biological markers that may closely reflect tumor biology and thereby clinical outcome. This article presents the current knowledge on the prognostic significance of p27 expression in cancer and its potential role as a target for future therapy.

Laparoscopic Conversion of Roux-en-Y Gastric Bypass to Sleeve Gastrectomy for Postprandial Hyperinsulinemic Hypoglycemia.

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) has proven to be a safe and effective treatment for obesity and its related comorbidities. However, RYGB may lead to uncommon, but occasionally difficult to treat complications such as postprandial hyperinsulinemic hypoglycemia (PHH) [1]. PHH is a condition characterized by hypoglycemic symptoms occurring 1-3 h after a meal, accompanied by low plasma glucose levels, typically preceded by a rise in both glucose and insulin concentrations [2]. The incidence of PHH is unknown and is probably underdiagnosed, as many patients are asymptomatic. The goal for the treatment of PHH after RYGB are to moderate postprandial fluctuations in plasma glucose, reduce insulin secretion, and ultimately reduce hypoglycemia [3]. Therapeutic options can be divided into medical and surgical. In cases of refractory patients, surgical treatment options include partial or total pancreatectomy, or a RYGB reversal procedure accompanied by gastric pouch restriction [4, 5]. METHODS: We present a 27-year-old female who underwent RYGB for morbid obesity. Two years post-surgery, she was referred to the ER due to tremor, palpitations, and syncope. On investigation, her capillary glucose was as low as 37 mg%. The hypoglycemic episodes repeated a few times a day. A comprehensive investigation included a 72 h fasting test, blood tests-serum C peptide and insulin, plasma sulfonylurea, anti-insulin ab, abdominal CT, MRI, octreotide test, and EUS. None of the tests showed any pathology, and she was given the diagnosis of PHH and was treated medically with diazoxide and acrabose without improvement. Surgical options were discussed with the patient and a conversion of the RYGB to sleeve gastrectomy was scheduled. RESULTS: In this video, we show how to revise an RYGB to treat PHH, by converting the RYGB to a sleeve gastrectomy. The intervention starts by restoring the normal anatomy of the small bowel with resection of the 100-cm Roux limb. Then, the greater curvature of the bypassed stomach was resected. A standard LSG around a 34Fr bougie was performed. A gastro-gastric anastomosis was fashioned between the pouch and the remnant stomach. The patient's operative and post-operative course was unremarkable with no further hypoglycemic episodes to date after 1-year follow-up. CONCLUSIONS: This technique was shown to be safe and effective as a part of the surgical treatment of post- bariatric PHH.

The use of Ursolit for gallstone prophylaxis following bariatric surgery: a randomized-controlled trial.

BACKGROUND: Although bariatric surgery (BS) predisposes patients to development of gallstone formation, a preventive strategy is still in debate. AIM: To compare the incidence of gallstone formation between patients treated with ursodeoxycholic acid (UDCA) vs. placebo for a duration of 6 months following BS. METHODS: This multicenter randomized, double-blind controlled trial entails treatment with UDCA vs. an identical-looking placebo. The primary outcome was gallstone formation, as measured by abdominal ultrasound. RESULTS: The data of 209 subjects were enrolled in the study, and 92 subjects completed the study and were analyzed (n = 46 for each study group). The high dropout rate was mainly due to difficulties in adding more medications and swallowing the pill. Among the subjects who completed the study, 77.2% were women, and their mean age and pre-surgery BMI were 42.2 ± 10.2 years and 44.4 ± 6.1 kg/m2, respectively. Gallstone formation was recorded in 45.7% (n = 21) vs. 23.9% (n = 11) of subjects among placebo vs. UDCA groups, respectively, p = 0.029. Subgroup-analysis, according to surgery type, found that the results were significant only for SG subjects (p = 0.041), although the same trend was observed for OAGB/RYGB. Excess Weight Loss percent (%EWL) at 6 months post-surgery was 66.0 ± 17.1% vs. 71.8 ± 19.5% for the placebo and UDCA groups, respectively; p = 0.136. A trend towards a reduction in prescribed comorbidity medications was noted within-groups during the follow-up period, as compared to baseline, with no between-group differences (p ≥ 0.246). Moreover, no between-group differences were found for blood test results (p ≥ 0.063 for all). CONCLUSION: Administration of UDCA significantly decreased gallstone formation at 6 months at following BS. CLINICALTRIALS. GOV NUMBER: NCT02319629.

The expression and prognostic significance of Cks1 in salivary cancer.

Cks1 is an essential factor in facilitating Skp2-dependent degradation of p27, but its role in salivary malignancies is unknown. Expression of cyclin-dependent kinase subunit 1 (Cks1) was examined in 64 salivary malignancies, compared with p27, S-phase kinase protein 2 (Skp2), Ki-67, p53, and TDT-mediated dutp-biotin nick end labeling (TUNEL) expression, and with THE patient's clinical and pathological parameters. Cks1 expression was markedly increased in 30 patients (47%) and strongly correlated with increased expression of Skp2, Ki-67, p53, and TUNEL, but inversely with p27 levels. High expression of Cks1 WAS strongly associated with lymph node metastases and poor prognosis and survival. Cks1 alterations may have a significant biological role in the pathogenesis of salivary cancer.

Left-sided perforated acute appendicitis in an adult with midgut malrotation: the role of computed tomography.

We report a case of left-sided perforated acute appendicitis in the patient with midgut malrotation. Embryology, clinical findings, and radiological presentation are discussed. Highly prevalent disease presents here in the unusual location and thus in the unusual presentation. The emergency room physician and radiologist should be aware of these unique clinical presentations so that appropriate surgical intervention may be initiated promptly.

Large-scale air-medical transport from a peripheral hospital to level-1 trauma centers after remote mass-casualty incidents in Israel.

INTRODUCTION: Mass-casualty incidents (MCIs) result in the evacuation of many patients to the nearest medical facility. However, an overwhelming number of patients and the type and severity of injuries may demand rapid, mass airmedical transport to more advanced medical centers. This task may be challenging, particularly after a MCI in a neighboring country. The Israeli Air Force Rescue and Airmedical Evacuation Unit (RAEU) is the main executor of airmedical transport in Israel, including MCIs. PROBLEM: The available data on airmedical transport from remote MCIs are limited.The objective of this study was to evaluate the airmedical transport from a rural hospital after two remote MCIs. METHODS: The study was retrospective and reviewed descriptive records of airmedical transports. RESULTS: The RAEU was involved in airmedical transports from a peripheral hospital shortly after two remote MCIs that occurred in the Sinai desert near the Egyptian-Israeli border. Nineteen (22.4%) and 25 (100%) of the treated trauma patients from each event were airmedically transported to Level-1 Trauma Centers in Israel within hours of the dispatch.The rapid dispatch and accumulation of medical personnel and equipment was remarkable. The airmedical surge capacity was broad and sufficient. Cooperation with local authorities and a tailored boarding procedure facilitated a quality outcome. CONCLUSIONS: The incorporation of a large-scale airmedical transport program with designated multidisciplinary protocols is an essential component to a remote disaster preparedness plan.

Over-expression of Skp2 is associated with resistance to preoperative doxorubicin-based chemotherapy in primary breast cancer.

INTRODUCTION: Preoperative chemotherapy is often used in patients with locally advanced breast cancer. However, commonly used clinical and pathological parameters are poor predictors of response to this type of therapy. Recent studies have suggested that altered regulation of the cell cycle in cancer may be involved in resistance to chemotherapy. Over-expression of the ubiquitin ligase Skp2 results in loss of the cell cycle inhibitor p27Kip1 and is associated with poor prognosis in early breast cancer. The purpose of the present study was to examine the role of these proteins as predictors of clinical outcome and response to chemotherapy in locally advanced breast cancer. METHODS: The expression levels of Skp2 and p27Kip1 were determined by immunohistochemistry both before and after preoperative chemotherapy in 40 patients with locally advanced breast cancer. All patients were treated with cyclophosphamide/doxorubicin (adriamycin)/5-fluorouracil (CAF) and some patients received additional treatment with docetaxel. Expression data were compared with patients' clinical and pathological features, clinical outcome, and response to chemotherapy. RESULTS: Skp2 expression before preoperative chemotherapy was inversely related to p27Kip1 levels, tumor grade, and expression of estrogen and progesterone receptors. Both Skp2 and p27Kip1 were found to be accurate prognostic markers for disease-free and overall survival. High preoperative expression of Skp2 was associated with resistance to CAF therapy in 94% of patients (P < 0.0001) but not with resistance to docetaxel. CONCLUSION: Skp2 expression may be a useful marker for predicting response to doxorubicin-based preoperative chemotherapy and clinical outcome in patients with locally advanced breast cancer.