Thoracic Duct Visualization in Esophageal Resection: A Pilot Trial.

INTRODUCTION: Inadvertent thoracic duct injury is common during esophagectomy and may result in postoperative chylothorax. This study's objective was to investigate utility of patent blue injection as a modality for intraoperative thoracic duct visualization. METHODS: A prospective, single-arm, interventional study of patients undergoing minimally invasive esophagectomy was performed. Patients were injected with patent blue dye into both groins prior to thoracic stage of surgery and assessed for duct visualization. Control group was formed by propensity score matching using retrospectively collected data regarding patients who underwent esophagectomy. RESULTS: A total of 25 patients were included in analysis, compared to a control of 50 patients after matching. Thoracic duct was visualized in 60% of patients in the study group (15/25 patients). Significant differences were found between study and control groups (p < 0.05) with regards to median operative time (422 vs. 285 min, respectively), overall complications (16 vs. 34%, respectively), and median postoperative length of stay (13.5 vs. 10 days, respectively). There was a difference in rate of chyle leak between study and control groups; however, this was not significant (0 vs. 12%, respectively, p = 0.17). CONCLUSION: Patent blue injection represents a simple method for thoracic duct visualization during minimally invasive esophagectomy which may improve surgical outcomes.

Sarcopenia as a Predictor of Survival in Patients with Pancreatic Adenocarcinoma After Pancreatectomy.

OBJECTIVE: To determine whether sarcopenia can potentially predict worse survival after resection of pancreatic ductal adenocarcinoma. BACKGROUND: Sarcopenia is correlated with poor outcomes in hepatopancreatobiliary malignancies, but the relationship of both its qualitative and quantitative features with patient survival after pancreatectomy has not been investigated in a western population. PATIENTS AND METHODS: Preoperative cross-sectional computed tomography scans of consecutive patients who underwent pancreatectomy in 2005-2017 were evaluated for skeletal muscle index (SMI), intramuscular adipose tissue content (IMAC), and visceral-to-subcutaneous adipose tissue area ratio (VSR). Sex-specific categorical cut-offs were determined. Findings were correlated with outcome. RESULTS: The study included 111 patients, 47% of whom were female, with a median age of 67 years (range: 35-87 years), and median body mass index of 23 kg/m2 (range: 16-40 kg/m2); 77% had a Whipple procedure and 66% received adjuvant chemotherapy. Low SMI correlated with poor overall survival (OS) (P = 0.007), disease-specific survival (DSS) (P = 0.006), and recurrence-free survival (RFS) (P = 0.01). High IMAC correlated with poor OS (P = 0.04). Patients with high IMAC tended to have a shorter DSS (P = 0.09), with no correlation with RFS (P = 0.6). VSR was not associated with survival. Multivariable analysis yielded an independent association of low SMI with OS (HR = 1.7, 95%CI: 1.1-2.8, P = 0.02), DSS (HR = 1.8, 95%CI: 1.03-3.2, P = 0.04), and RFS (HR = 1.8, 95%CI: 1.1-2.8, P = 0.01), and of high IMAC with OS (HR = 1.9, 95%CI: 1.1-3.1, P = 0.01). CONCLUSION: Both qualitative and quantitative measures of skeletal muscle were independently associated with impaired survival in patients with resectable PDAC. Sarcopenia might serve as an early radiographic surrogate of aggressive tumor behavior, with potential implications for clinical decision-making and future study.

Artificial intelligence for phase recognition in complex laparoscopic cholecystectomy.

BACKGROUND: The potential role and benefits of AI in surgery has yet to be determined. This study is a first step in developing an AI system for minimizing adverse events and improving patient's safety. We developed an Artificial Intelligence (AI) algorithm and evaluated its performance in recognizing surgical phases of laparoscopic cholecystectomy (LC) videos spanning a range of complexities. METHODS: A set of 371 LC videos with various complexity levels and containing adverse events was collected from five hospitals. Two expert surgeons segmented each video into 10 phases including Calot's triangle dissection and clipping and cutting. For each video, adverse events were also annotated when present (major bleeding; gallbladder perforation; major bile leakage; and incidental finding) and complexity level (on a scale of 1-5) was also recorded. The dataset was then split in an 80:20 ratio (294 and 77 videos), stratified by complexity, hospital, and adverse events to train and test the AI model, respectively. The AI-surgeon agreement was then compared to the agreement between surgeons. RESULTS: The mean accuracy of the AI model for surgical phase recognition was 89% [95% CI 87.1%, 90.6%], comparable to the mean inter-annotator agreement of 90% [95% CI 89.4%, 90.5%]. The model's accuracy was inversely associated with procedure complexity, decreasing from 92% (complexity level 1) to 88% (complexity level 3) to 81% (complexity level 5). CONCLUSION: The AI model successfully identified surgical phases in both simple and complex LC procedures. Further validation and system training is warranted to evaluate its potential applications such as to increase patient safety during surgery.

The Dynamic Changing Incidence of Gastric Cancer in Israel: Time for a National Surgical Management Committee?

BACKGROUND: There has been a general reduction over the last 20 years in the incidence within Israel of gastric cancer (GC). This has particularly been noted in the Jewish population with a slight increase in the incidence of cancer of the gastroesophageal junction among Jews of Sephardi origin. Given the diversity of individual ethnic subpopulations, the effects of GC incidence in second-generation immigrant Jews, particularly from high prevalence regions (e.g., the former Soviet Union, Iraq, and Iran), awaits determination. There are currently no national data on GC-specific mortality. The most recent available cross-correlated Israeli National Cancer Registry (INCR) and International Association for Cancer Research (IARC) incidence data for GC of the body and antrum in Israel are presented. Some of the challenges associated with GC monitoring in the changing Israeli population are discussed. We propose the establishment of a national GC management committee designed to collect demographic and oncological data in operable cases with the aim of recording and improving GC-specific outcomes. We believe that there is value in the development of a national surgical planning program, which oversees training and accreditation in a dynamic environment that favors the wider use of neoadjuvant therapies, minimally invasive surgery and routine extended (D2) lymphadenectomy. These changes should be supported by assessable enhanced recovery programs.

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

BACKGROUND: Studies have suggested that neutrophil-to-lymphocyte ratio (NLR) has value as a predictor of long-term outcomes in various cancer types. Its prognostic potential in patients with CRLM has not been thoroughly investigated. This original, retrospective study assessed the relationship between the preoperative NLR, survival outcomes, and recurrence patterns in patients after colorectal liver metastasis resection (CRLM). METHODS: The prospectively maintained database of a tertiary medical center was queried for all patients who underwent CRLM resection between 2005 and 2017. Patients were divided into two groups: NLR <3 (normal) or >3 (high). Recurrence risk was analysed using Fine and Gray correction for competing risk method and cause specific analyses. RESULTS: The cohort included 231 patients of whom 53 (23%) had a high neutrophil-to-lymphocyte ratio. At presentation, 35% had synchronous disease and 48% had a solitary metastasis; median tumor size was 2 cm. Patients with a high NLR had a significantly higher rate of simultaneous colorectal resection (P = 0.01). A high NLR was independently associated with worse OS (P = 0.02), worse DFS (P = 0.03), and higher risk of recurrence (P = 0.048), specifically recurrence with an extrahepatic pattern (P = 0.03). CONCLUSIONS: A high preoperative NLR was independently associated with poorer survival outcomes and extrahepatic recurrence pattern. The NLR appears to have prognostic importance in CRLM and may serve as a surrogate marker of aggressive systemic disease after resection. These findings warrant external validation, preferably in a prospective design.

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

BACKGROUND: While the prognosis of patients with locoregional esophageal adenocarcinoma (EAC) has improved in the neoadjuvant treatment (NAT) era, high-grade histology (G3) is still associated with a limited treatment response. We sought to investigate oncologic outcomes in patients after esophagectomy for G3 EAC and to identify predictors of poor survival among these patients. METHODS: Patients with EAC who underwent resection with curative intent in 2011-2018 were divided by histologic grade (G3, G1/2) and compared for overall survival (OS). Cox regression was performed to analyze the response to NAT and the predictive role of signet ring cell (SRC) features. RESULTS: The cohort included 163 patients, 94 (57.7%) with G3 histology. NAT was administered to 69 (73.4%) patients. Following resection, OS in the G3 EAC group was 30 months (95% confidence interval [CI] 23.9-36.1). On univariate analysis, G3 disease (p = 0.050) and SRC features (p = 0.019) predicted low OS. Median survival in the G3 EAC group was worse in patients with SRC histology (18 months, 95% CI 8.6-27.4) than those without (30 months, 95% CI 23.8-36.1; p = 0.041). No patients with SRC histology were alive at 5 years of follow-up. Among all patients administered NAT, 88.2% of those with SRC showed minimal or no pathologic response and only 27.8% were downstaged. CONCLUSIONS: High-grade histology was found in most patients with EAC and predicted poor survival and treatment response. SRC features in patients with G3 disease were associated with lower OS. The benefit of NAT for G3 EAC in patients with SRC histology appears limited.

Robotic-assisted Heller Myotomy Is a Safe Operation.

BACKGROUND: Surgical myotomy is the best therapeutic option for patients with achalasia. The minimally invasive technique is considered to be the preferred method for many surgeons. Robotic-assisted laparoscopic myotomy has several advantages over conventional laparoscopic surgery. These benefits include more accurate incisions that may result in a lower rate of intra-operative complications. OBJECTIVES: To describe our technique of performing robotic-assisted Heller myotomy and to review the initial results of this procedure. METHODS: All patients undergoing robotic-assisted Heller myotomy for achalasia between the years 2012-2018 at Rabin Medical Center were retrospectively reviewed from our institutional prospective database. RESULTS: Thirty patients underwent robotic-assisted Heller myotomy for achalasia. Mean operative time was 77 minutes (range 47-109 minutes) including docking time of the robotic system. There were no cases of conversion to laparoscopic or open surgery. There were no cases of intra-operative perforation of the mucosa. None of the patients had postoperative morbidity or mortality. Good postoperative results were achieved in 25 patients. Four patients required additional intervention (3 had endoscopic dilatations and 1 with known preoperative endstage achalasia had undergone esophagectomy). One patient was lost to follow-up. CONCLUSIONS: Robotic-assisted Heller myotomy is a safe technique with a low incidence of intra-operative esophageal perforation compared to the laparoscopic approach. We believe that robotic-assisted surgery should be the procedure of choice to treat achalasia.

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

OBJECTIVE: Gastric cancer (GC) is a leading cause of cancer death, occurs predominantly in older age, with increasing incidence in young patients. The Cancer Genome Atlas indicates four subtypes for GC among which Epstein-Barr virus (EBV) subtype is estimated at 8.7%. We aim to determine the prevalence of EBV subtype in young GC patients (≤45 years) compared with an average-onset cohort (≥55 years) and characterize the clinicopathologic pattern of young-onset GC. METHODS: Gastric cancer samples of patients of both cohorts were screened for EBV by qPCR. Additional staining was done for Human epidermal growth factor receptor 2 (HER2), microsatellite instability (MSI) status and Programmed death-ligand 1 (PD-L1). Demographics and clinical data were retrieved from the medical records. RESULTS: Thirty-nine young-onset and 35 average-onset GC patients were reviewed. There was no apparent difference in tumor location, family history, histology and HER2 status between the cohorts. More young-onset patients were diagnosed with metastatic disease (27% vs 9%, p = 0.0498). EBV was significantly more prevalent in the young-onset cohort (33% vs 11%, p = 0.025). 15/17 EBV positive patients were under the median age of diagnosis for GC in the US (68 years). MSI-H was found only in the average-onset cohort [0% vs 27%, p = 0.001). PD-L1 positivity was higher in the young-onset cohort (31% vs 3%, p = 0.002). CONCLUSION: Our study indicates that EBV subtype is more prevalent in young-onset GC and may play a key role in the pathogenesis. Higher rate of PD-L1 positivity in young-onset GC could change treatment strategies. We are currently evaluating these findings in a prospective trial.

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

BACKGROUND: Left ventricular assist devices (LVADs) are used more commonly in patients with advanced-stage heart failure. Some of these patients may require elective or urgent abdominal surgical procedures. OBJECTIVES: To determine the outcomes of the management of LVAD-supported patients who underwent elective and urgent abdominal surgical procedures in our institution. METHODS: A retrospective review was conducted on 93 patients who underwent LVAD implantation between August 2008 and January 2017. All abdominal surgeries in these patients were studied, and their impact on postoperative morbidity and mortality Ten patients underwent abdominal surgical procedures. Of these procedures, five were emergent and five were elective. The elective cases included one bariatric surgery for morbid obesity, one hiatal hernia repair, two cholecystectomies, and one small bowel resection for a carcinoid tumor. The emergency cases included suspected ischemic colitis, right colectomy for bleeding adenocarcinoma, laparotomy due to intraabdominal bleeding, open cholecystectomy for gangrenous cholecystitis, and laparotomy for sternal and abdominal wall infection. All patients undergoing elective procedures survived. Of the five patients who underwent emergency surgery, three died (60%, P = 0.16) and one presented with major morbidity. One of the two survivors required reintervention. In total, 12 interventions were performed on this group of patientswas evaluated. RESULTS: Ten patients underwent abdominal surgical procedures. Of these procedures, five were emergent and five were elective. The elective cases included one bariatric surgery for morbid obesity, one hiatal hernia repair, two cholecystectomies, and one small bowel resection for a carcinoid tumor. The emergency cases included suspected ischemic colitis, right colectomy for bleeding adenocarcinoma, laparotomy due to intraabdominal bleeding, open cholecystectomy for gangrenous cholecystitis, and laparotomy for sternal and abdominal wall infection. All patients undergoing elective procedures survived. Of the five patients who underwent emergency surgery, three died (60%, P = 0.16) and one presented with major morbidity. One of the two survivors required reintervention. In total, 12 interventions were performed on this group of patients. CONCLUSIONS: It is safe to perform elective abdominal procedures for LVAD-supported patients. The prognosis of these patients undergoing emergency surgery is poor and has high mortality and morbidity rates.

[EVALUATION OF THE ELDERLY PATIENT WITH CANCER].

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

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

INTRODUCTION: The Israeli Scientific Council is responsible for the physician's training process and the residency exams. These are performed in two phases: Stage A (written examination) and Stage B (the final Board oral examination). The COVID-19 pandemic started in Israel a few weeks before the scheduled spring 2020 Stage B exams and had a major impact, not only on the health and economic systems in Israel, but also on the residency exams. AIMS: To describe the efforts of the Israeli Scientific Council to execute the spring 2020 Stage B exams during the COVID-19 pandemic in comparison to the worldwide data, and to deduce the appropriate management during potential future crises. METHODS: We present a description of the activity of the Israeli Scientific Council since the start of the COVID-19 pandemic according to documents and other sources, An internet search was conducted on the destiny of residency examinations throughout the world, and a comparison between them. RESULTS: Due to rapid worsening in the restrictions enforced in Israel, the spring 2020 oral board exams were cancelled. However, a decision was made to execute them in the summer. This new schedule dictated a delay in the schedule of other residency examinations and forced condensation of 5 periods into 10 months instead of 14. The examination team prepared the new summer exams period under the assumption that heavy restrictions will still be implemented. Indeed, COVID-19 was still around and the restrictions were still enforced. Despite that, all oral Board examinations were perfectly executed. This contrasts with the rest of the world, in which most residency exams were cancelled, even without a solution or an alternative date. CONCLUSIONS: Recruitment of all involved and preparation for the worst-case scenario enabled the perfect execution of the previously cancelled exams, and will enable the execution of future residency exams under conditions of potential health or war crises. DISCUSSION: To the best of our knowledge, the Israeli Scientific Council is the only communal body in the world which organized an alternative period for the cancelled oral exams, only 4 months after the cancelled dates. Due to an enormous effort and rigorous preparations, Israel is also the only place in which oral exams were successfully executed, physically, under an active disease and very heavy restrictions.

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

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

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

CONTEXT: The role of the laparoscopic left lateral sectionectomy (LLLS) is debatable, and Level-1 data are lacking. AIMS: The aim of the study is to evaluate the feasibility and safety of this approach. SETTINGS AND DESIGN: This was a retrospective study. SUBJECTS AND METHODS: From 2007 to 2014, patients undergoing LLLS were identified from two institutions. STATISTICAL ANALYSIS USED: Continuous variables were compared between groups with Student's t-test or Mann-Whitney test, as appropriate by type of distribution. Categorical variables were compared with Chi-square or Fisher's exact test, depending on the number of observations. RESULTS: Thirty-eight patients were included in the study. The mean age was 63.5 + 13 years (range, 31-89), and the mean number of tumours was 1.7 + 1.5. Eleven (29%) patients underwent LLS combined with an additional liver resection (combined resections group). The mean duration of the operation and the mean estimated blood loss were significantly decreased in the LLS group compared to the combined resection group (101 + 71 min vs. 208 + 98 min and 216 + 217 ml vs. 450 + 223 ml;P < 0.05 for both, respectively). The major complications rate was 8% and no mortality occurred. CONCLUSIONS: In a subset of carefully selected cases, LLLS may provide the benefits of laparoscopy. This does not appear to compromise perioperative morbidity rates. We believe that this approach may serve as a training platform for surgical trainees.

Isolated Traumatic Brain Injury in the Very Old.

BACKGROUND: Older age is an independent predictor of worse outcome from traumatic brain injury (TBI). No clear guidelines exist for the management of TBI in elderly patients. OBJECTIVES: To describe the outcomes of elderly patients presenting with TBI and intracranial bleeding (ICB), comparing a very elderly population (≥ 80 years of age) to a younger one (70-79). METHODS: Retrospective analysis of the outcomes of elderly patients presenting with TBI with ICB admitted to a level I trauma center. RESULTS: The authors analyzed 100 consecutive patients aged 70-79 and 100 patients aged 80 and older. In-hospital mortality rates were 9% and 21% for groups 70-79 and ≥ 80 years old, respectively (P = 0.017). Patients 70-79 years old showed a 12-month survival rate of 73% and a median survival of 47 months. In patients ≥ 80 years old, 12-month survival was 63% and median survival was 27 months (P = NS). In patients presenting with a Glasgow Coma Scale score of ≥ 8, the in-hospital mortality rates were 41% (n=5/12) and 100% (n=8/8). Among patients ≥ 80 years old undergoing emergent surgical decompression, in-hospital mortality was 66% (n=12/18). Survivors presented with a severe drop in their functional score. Survival was dismal in patients ≥ 80 years old who were treated conservatively despite recommended operative guidelines. CONCLUSIONS: There is a lack of reliable means to evaluate the outcome in patients with poor functional status at baseline. The negative prognostic impact of severe TBI is profound, regardless of treatment choices.

[POSTGRADUATE MEDICAL EDUCATION ACCREDITATION IN ISRAEL].

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

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

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.

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

BACKGROUND: Unlike the elective treatment of metastatic colorectal cancer (MCRC), sufficient data and consensual guidelines on acute care are lacking. OBJECTIVES: To analyze a cohort of MCRC patients who required urgent surgery due to acute abdomen and to identify risk factors contributing to the patient's perioperative mortality and morbidity. METHODS: A retrospective analysis was conducted of patients diagnosed with stage IV colorectal cancer who required urgent laparotomy at the Rabin Medical Center. Comparative analysis was performed using Pearson's chi-square and Student`s t-test. RESULTS: Between 2010 and 2015, 113 patients underwent urgent laparotomy due to colorectal cancer complications, of which 62 patients were found to have a metastatic, stage IV, disease. Large bowel obstruction was the most common indication for urgent laparotomy. In-hospital mortality was 30% (n=19), and overall 30 day mortality was 43%. Fifteen patients (24%) required more than one surgery. The average length of hospital stay was 21 days. Age and lactate levels at presentation were the only prognostic factor found for mortality (P < 0.05). CONCLUSIONS: MCRC laparotomy patients incur a significant burden of care and have a relatively high incidence of early mortality. Our data suggest high, verging on unacceptable, mortality and complication rates in this subgroup of patients. This finding is further accentuated in the subgroup of older patients presenting with lactatemia. These data should be considered by surgeons when discussing treatment options with patients and families.

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

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.

[LAPAROSCOPIC "SLEEVE" GASTRECTOMY POST HEART TRANSPLANTION].

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