[SURGICAL TREATMENT USING ROBOTIC APPROACH FOR OBSTRUCTED DEFECATION SYNDROME (ODS)].

INTRODUCTION: Obstructed Defecation Syndrome (ODS) is a complex surgical condition which involves structural and functional problems which significantly affects quality of life. There is limited information about the Da-Vinci Robotic System use in the treatment of this condition. This study examines the outcomes of robotic-assisted rectopexy. The primary outcome is recovery from surgery, with secondary outcomes including post-surgical complications, length of hospital stay, rehospitalization rate and recurrence after surgery. METHODS: A retrospective analysis was conducted of prospectively collected data for patients who underwent robotic assisted surgery for ODS between 2011-2022. A colorectal surgeon performed all surgeries at the Sheba Medical Center using the Da Vinci™ robotic system. This analysis uses descriptive statistics and presents the results as medians and ranges. RESULTS: Out of 33 patients included, 26 (84.9%) were female. Median age was 67 years (Range:19-85 years). Median American Society of Anesthesiology (ASA) score was 2 (1-3). Median Charlson's comorbidity score was 3 (0-4). Median patients' Body Mass Index (BMI) was 23.2 (15.6-33.4) kg/m2. Eight patients (24.4%) underwent previous procedure for ODS. Most (23) patients included (69.7%) underwent robotic assisted ventral rectopexy. Other interventions included combined anterior and posterior rectopexy (9.1%), combined ventral rectopexy and sacrocolpopexy (12.1%) and posterior rectopexy (9.1%). No cases of conversion to laparoscopic /open techniques were recorded. Median operation time was 135 minutes (70-270). One intra-operative complication recorded was an injury to the rectum during anterior dissection (3%). No significant blood loss was recorded. A total of 27 patients (81.8%) were operated using the Da Vinci Si system, and the rest (6) using the 6 Da Vinci Xi system. Two patients had post-operative complications. Median length of stay (LOS) was 4 days (2-6 days). Readmission rate within 30 days was 9.1%. Two patients (6.1%) had recurrence of rectal prolapse. Median follow-up was 60 (4-116) months. CONCLUSIONS: Robotic-assisted surgery for obstructed defecation syndrome is safe, with fast recovery of the patient and it is efficient during long-term follow-up.

The Impact of the Donor Card Holder Prioritization Program on Kidney Allocation in Israel.

BACKGROUND: Since 2014, as part of a priority program within the Israeli Transplant Law, additional points were given to waitlisted candidates with donor cards. We assessed the impact on deceased donor kidney allocation. METHODS: This study enrolled all patients older than 18 y who underwent deceased donor kidney transplantation (January 2016-December 2019). Data were obtained from the National HLA Tissue Laboratory registry at the Sheba Medical Center. Patients were grouped by donor card status (ADI group) (not signed, 0 points; relative signed, 0.1 points; patient signed, 2 points; and relative donated, 9 points). The primary outcome was waiting time until kidney transplantation with and without the additional score. RESULTS: Four hundred forty-four patients underwent kidney transplantation during the study period: 281 (63%) were donor card holders (DCH) and 163 (37%) were not DCH. DCH with extra points waited 68.0 (±47.0) mo on average, compared with 94.6 (±47.3) mo for not DCH ( P  < 0.001). Donor card signers had a shorter time until transplant in a multivariable model. Without extra points, 145 recipients (32.6%) would have missed organs allocated to higher-scored candidates. Allocation changes occurred in 1 patient because of an additional 0.1 points, in 103 candidates because of an additional 2 points, and in 41 candidates because of an additional 9 points. CONCLUSIONS: Additional DCH scores improved allocation and reduced waiting time for donor card signers and those with donating relatives. To enhance fairness, consideration should be given to reducing the score weight of this social criterion and raising scores for other factors, especially dialysis duration.

Perioperative hypothermia and stress jeopardize anti-metastatic immunity and TLR-9 immune activation: potential mediating mechanisms (experimental studies).

BACKGROUND: The perioperative period often involves stress responses and surgery-induced hypothermia, which were suggested to hinder anti-metastatic immunity and promote cancer metastasis. During this critical period, immunotherapies are rarely used, given contraindications to surgery. However, recent pre-clinical studies support the feasibility of perioperative TLR-9 activation, using CpG-C. MATERIALS AND METHODS: Herein, we employed hypothermic- and normothermic-stress paradigms to assess their impact on perioperative CpG-C immune-stimulation and resistance to experimental hepatic metastasis of CT26 colorectal cancer in BALB/C mice. RESULTS: Perioperative hypothermic wet-cage stress markedly abrogated CpG-C-induced increase in plasma IL-12 levels, a persistent deleterious effect across different CpG-C doses and administration routes. These effects were not attenuated by blocking glucocorticoids, adrenergic, or opioid signaling, nor by adrenalectomy, suggesting direct immunosuppressive impact of hypothermia on immunocytes. Indeed, normothermic wet-cage stress, which induced similar corticosterone response, caused significantly less deleterious effects on IL-12 levels, hepatic NK cell maturation and cytotoxicity, and CT26 metastasis. Additionally, in vitro exposure of PBMCs to 33°C markedly decreased CpG-C-induced IL-12 production. Last, two normothermic stress paradigms, tilt&light and restraint, did not jeopardize CpG-C-induced IL-12 response nor resistance to CT-26 metastases. Interestingly, attenuating glucocorticoid signaling under tilt&light conditions improved CpG-C efficacy. CONCLUSIONS: Overall, these findings suggest that perioperative hypothermic stress can jeopardize anti-metastatic immunity and resistance to metastasis, and prevent perioperative response to immune stimulation and its beneficial anti-metastatic impacts, effects that are not mediated through classical neuroendocrine stress responses, but potentially through direct hypothermic impact on leukocytes. These findings may have clinical implications in operated cancer patients, many of whom suffer hypothermic stress.

Basiliximab induction alone vs a dual ATG-basiliximab approach in first live-donor non-sensitized kidney transplant recipients with low HLA matching.

Background: Individualizing induction therapy based on immunological risk is crucial for optimizing outcomes in kidney transplantation. Methods: A retrospective analysis included 157 first live-donor non-sensitized kidney transplant recipients (KTRs). Within this cohort, 96 individuals exhibited low human leukocyte antigen (HLA) matching (5-6 HLA mismatches). The low HLA match subgroup was categorized into 52 KTRs receiving basiliximab alone and 44 recipients treated with a combined single ATG dose of 1.5 mg/kg and basiliximab. The primary endpoint was early acute cellular rejection (ACR) within 6 months post-transplant while secondary outcomes encompassed infection rates, renal allograft function, length of stay (LOS) and readmissions post-transplant. Results: The incidence of early ACR was decreased for low HLA match KTRs, who received ATG-basiliximab, when compared with low HLA-matched KTRs who received basiliximab alone (9.1% vs 23.9%, P = .067). Age was a predictor for rejection, and subgroup analysis showed consistent rejection reduction across age groups. No significant differences were observed in admission for transplant LOS or in peri-operative complications, nor in infections rate including BK and cytomegalovirus viremia, allograft function and number of readmissions post-transplant up to 6 months post-transplant. Conclusion: In non-sensitized first live-donor KTRs with low HLA matching, a dual ATG-basiliximab induction approach significantly reduced early ACR without compromising safety.

Gastric Bypass as a Third Bariatric Procedure-Our Experience with 42 Cases.

BACKGROUND: It is not uncommon to encounter patients seeking a third, fourth, or even fifth bariatric procedure. With higher expected complication rates and questionable patient benefit, the indication for multiple revisions is still in doubt. To evaluate the perioperative and post-operative outcomes of patients undergoing gastric bypass after two previous bariatric surgeries or more. METHODS: We identified all patients that underwent gastric bypass following at least 2 previous bariatric surgeries. We looked at patient demographics, previous bariatric surgeries, pre-operative body mass index (BMI) and obesity-related co-morbidities, perioperative complications, length of stay (LOS), re-admissions and re-operations, percentage of excess weight loss, and resolution or improvement in comorbidities. RESULTS: Forty-two patients met the inclusion criteria, the majority being females (31, 73.8%). Average age was 45.6 years (range 27-62), average weight and BMI was 116 kg (range 75-175 kg) and 41.1 kg/m2 (range 25.6-58.7 kg/m2), respectively. Thirty-two patients had two previous bariatric surgeries (73.8%), and 10 patients had 3 former bariatric surgeries (23.8%), and for one patient, this was the fifth bariatric procedure (2.4%). Mean LOS was 10 days (range 2-56 days). Eight patients (19%) needed re-admission and 5 (11.9%) needed re-operation. At a median follow up of 48 months (range 7-99 months), the average BMI was 34.5 kg/m2 (range 23.7-55.1 kg/m2) reflecting an excess BMI loss of 43.3%. CONCLUSIONS: Gastric bypass as a third or more bariatric procedure is effective yet associated with high complication rates, re-admissions, and re-operations.