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.

[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.

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.

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 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.

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.

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 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.

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.

Unusual presentation of epidermoid cyst mimicking breast cancer involving the areola-Case report.

INTRODUCTION: Epidermoid cyst is very common benign lesion of the skin. And may appear anywhere on the surface of the body. Diagnosis is made in most cases by clinical examination, but histological evaluation may be needed in unusual cases. PRESENTATION OF CASE: We report a rare case of a 44 year-old woman who presented with a rapidly growing inflamed mass localized to the left areola, which grew to 4 cm in diameter within a few months. The diagnosis of malignancy was ruled out following pathology examination consistent with epidermoid cyst. After a course of antibiotics, she underwent surgery with nipple sparing and reconstruction of the areola. DISCUSSION: Preoperative diagnosis based on biopsy enable limited surgical excision and preservation of the nipple. Reconstruction of the areola by local areolar flap enable good aesthetic result. CONCLUSION: It is important to be aware of this entity of epidermoid cyst mimicking breast cancer, and the treatment options available in these cases.

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.

Correction to: Incidence and Risk Factors for Mortality Following Bariatric Surgery: a Nationwide Registry Study.

In Table 5 the P value for the parameter "More than one chronic disease" is incorrect. The correct value is 0.387, not 0.0387.

Incidence and Risk Factors for Mortality Following Bariatric Surgery: a Nationwide Registry Study.

BACKGROUND: Although bariatric surgery (BS) is considered safe, concern remains regarding severe post-operative adverse events and mortality. Using a national BS registry, the aim of this study was to assess the incidence, etiologies, and risk factors for mortality following BS. METHODS: Prospective data from the National Registry of Bariatric Surgery in Israel (NRBS) including age, gender, BMI, comorbidities, and surgical procedure information were collected for all patients who underwent BS in Israel between June 2013 and June 2016. The primary study outcome was the 3.5-year post-BS mortality rate, obtained by cross-referencing with the Israel population registry. RESULTS: Of the 28,755 patients analyzed (67.3% females, mean age 42.0 ± 12.5 years, and preoperative BMI 42.14 ± 5.21 kg/m2), 76% underwent sleeve gastrectomy (SG), 99.1% of the surgeries were performed laparoscopically, and 50.8% of the surgeries were performed in private medical centers. Overall, 95 deaths occurred during the study period (146.9/100,000 person years). The 30-day rate of post-operative mortality was 0.04% (n = 12). Male gender (HR = 1.94, 95%CI 1.16-3.25), age (HR = 1.06, 95%CI 1.04-1.09), BMI (HR = 1.08, 95%CI 1.05-1.11), and depression (HR = 2.38, 95%CI 1.25-4.52) were independently associated with an increased risk of all-cause 3.5-year mortality, while married status (HR = 0.43, 95%CI 0.26-0.71) was associated with a decreased risk. CONCLUSION: Mortality after BS is low. Nevertheless, a variety of risk factors including male gender, advanced age, unmarried status, higher BMI, and preoperative depressive disorder were associated with higher mortality rates. Special attention should be given to these "at-risk" BS patients.

Laparoscopic Repair of a Large Paraesophageal Hernia with Migration of the Stomach into the Mediastinum Creating an Upside-Down Stomach.

Upside-down stomach is a relatively rare type of a large paraesophageal hernia characterized by the migration of the stomach into the posterior mediastinum. Upside-down stomach is prone to severe complications and therefore surgery is recommended even in asymptomatic patients. A 62-year-old male presented with frequent abdominal pain with nausea and vomiting that persisted for one year. The patient was obese with fatty liver and was treated medically for gastroesophageal reflux disease (GERD) for 4 years. On upper gastrointestinal CT study a level-IV paraesophageal hernia was detected with upside-down stomach, and he was referred for elective surgery. Laparoscopic surgery included reduction of the stomach into the abdominal cavity followed by dissection of the paraesophageal membrane and hernia sac. The hiatal defect was closed using a wound closure device and nonabsorbable sutures. The defect closure was reinforced using Physiomesh tucked anteriorly and sutured posteriorly to the diaphragm. Follow-up was uneventful and the patient is free of complaints. The results of this surgical intervention support previous reports that laparoscopic repair with the use of biological mesh in the setting of large paraesophageal hernia should be favorably considered.

Microbiologic Data in Acute Cholecystitis: Ten Years' Experience from Bile Cultures Obtained during Percutaneous Cholecystostomy.

BACKGROUND: The aim of the study was to describe the microbiology and susceptibility patterns in acute cholecystitis by examining bile culture results from patients who underwent percutaneous cholecystostomy and examine concordance with empiric treatment. PATIENTS AND METHODS: A total of 124 patients with acute cholecystitis underwent percutaneous cholecystostomy between 2003 and 2012 at Emek Medical Center, Israel. Data on bile and blood culture results, isolate susceptibility, and clinical outcomes were retrieved from patient files. RESULTS: Bile cultures obtained from 116 patients were positive in 70 (60.3%) patients. Blood cultures obtained from 77 patients were positive in 23 (31.1%). Escherichia coli was the most common isolate in 28.6% of bile cultures and 43.5% of blood cultures. The concordance between empiric treatment coverage and culture isolate susceptibility was 67.6%. In most discordant cases, the isolates were Enterobacter spp. (40.9%) and Enterococcus spp. (31.8%). Overall, the in-hospital mortality rate was 7%: 2% in patients with concordant treatment compared with 14% in patients with discordant treatment (p = 0.09). Empiric antibiotic regimens were adequate in only two-thirds of patients. CONCLUSIONS: There might be a trend for poorer outcome in patients treated with inadequate antibiotic agents, emphasizing the importance of tailoring antibiotic treatment.