The Effect of Bariatric Surgery upon Diabetes Mellitus: A Proof of Concept by Using the Case of the Mid-Term Effect of Lap Adjustable Gastric Banding (LAGB) on Patients with Diabetes.

Obesity is a worldwide epidemic, with numbers on the rise in the world. Obesity is strongly correlated with increased morbidity and mortality. One of the major factors affecting this increase is comorbid diseases such as diabetes mellitus (DM), which is strongly associated with and dependent on the degree of obesity. Thus, it is not surprising that when efficient surgical treatments were found to battle obesity, researchers soon found them to be relevant and effective for battling DM as well. Laparoscopic Adjustable Gastric Banding (LAGB) is a common surgical treatment for morbid obesity. LAGB has the potential to improve control of the comorbidities of morbid obesity, primarily diabetes mellitus (DM). Our hypothesis was that patients treated with LAGB would have a long-term improvement in the control of DM and that due to its unique mechanism of action, this can lend us a better understanding of how to battle diabetes in an efficient and effective way. This was a cohort study based on patients who underwent LAGB surgery in our institution 4 to 7 years previously and had DM type 2 at the time of surgery. Data were collected from patient's charts and a telephone interview-based questionnaire including demographics, health status, and quality-of-life assessment (Bariatric Analysis and Reporting Outcome System [BAROS]). Seventy patients participated in the current study. The average follow-up time was 5.1 ± 0.9 years post-surgery. The average weight prior to surgery was 122.0 ± 20.2 kg, and on the day of the interview it was 87.0 ± 17.6 kg (p < 0.001). The average body mass index before surgery was 43.8 ± 5.1, and on the day of the interview it was 31.2 ± 4.8 (p < 0.001). On the day of the interview, 47.1% of the participants were cured of DM (not receiving treatment, whether dietary or pharmacologic). The sum of ranks for diabetes was lower after the surgery (p < 0.001), as was HTN and its treatment (p < 0.001). We have shown in this study that LAGB is an effective treatment for morbid obesity, as well as two comorbidities that come with it­DM type 2 and Hypertension (HTN)­in a longer period than previously shown, and with a unique look at the underlying mechanism of action of this procedure. There is a need for further studies to consolidate our findings and characterize which patients are more prone to enjoy these remarkable surgical benefits.

[LANDMARKS IN THE MEDICAL HISTORY OF ISRAEL - IS IT TRULY INTERWEAVING WITHIN THE ISRAELI POSTAL STAMP].

INTRODUCTION: Issuing postal stamps is the main sign of a nation's independence. The first stamps series of Israel were issued a mere two days after the declaration of Israel's independence. Since then, almost 1750 postal stamps were issued as a single unit or different stamps series. These stamps delineate and emphasize innovations, military and civilian technological developments, the high holidays and nature as well as respecting important national figures and holidays. The aim of our historical search of philately (stamps collection) through the 20th century till today was to find out the frequency of the interweaving of medicine, medical developments and the tribute to outstanding figures, in all medical fields, and their contribution during peace and war periods in Israeli stamps. The thorough research study revealed only 16 stamps that were issued perpetuating medical disciplines - 0.9% of all stamps. Despite their national and worldwide significance there were no stamps commemorating many medical and surgical fields. I did not find reminiscence of our military medical developments that have become a competent authority for numerous armies all over the world. Organ transplantation, surgical innovations and the large group of women physicians and surgeons that took leadership in several medical fields have no presence in our postal stamps. Nowadays, philately has lost its importance as a financial value for the prompt e-mails. I believe philately should be encouraged to issue current postal stamps dedicated to "blue and white" medicine, a thing that is even more adequate these days in which all the medical community was enlisted to battle the new corona pandemic.

Circulating Cell-free DNA in Patients With Acute Biliary Pancreatitis: Association With Disease Markers and Prolonged Hospitalization Time-A Prospective Cohort Study.

OBJECTIVE: To evaluate cfDNA as an indicator of pancreatitis severity. BACKGROUND: Acute pancreatitis severity scores have limited proficiency, and are complex and challenging to use clinically. Elevation of circulating cfDNA concentration has been shown to be associated with hospital length of stay (LOS) and mortality. METHODS: In a prospective study, cfDNA concentration was measured by a simple fluorometric test, at admission and for 2 consecutive days, in patients with acute biliary pancreatitis (ABP). Ranson and APACHE II scores were used as measures of pancreatitis severity. Hospital LOS and mortality were used as outcome measures. RESULTS: Seventy-eight patients were included. Patients with severe disease according to Ranson's Criteria (n = 24) had elevated median admission cfDNA compared to patients with mild disease (n = 54, 2252ng/ml vs 1228 ng/ml, P < 0.05 ). Admission cfDNA levels correlated with Ranson and APACHE II scores and markers of bile duct obstruction. LOS did not differ between patients with mild and severe disease according to Ranson and APACHE II scores. Patients with cfDNA at 24 hours concentrations above the cutoff value of healthy patients (>850 ng/ml) had a significantly longer LOS compared to those with normal cfDNA levels ( P < 0.001 ). CONCLUSIONS: cfDNA, measured by a rapid simple assay, proved a valuable early marker of severity in ABP with clear advantages for prediction of LOS over Ranson and APACHE II. Measurement of cfDNA has the potential to be an effective practical approach to predict the course of ABP and should be further evaluated in larger trials.

Measles Virus Persistent Infection of Human Induced Pluripotent Stem Cells.

In this study, we found that the measles virus (MV) can infect human-induced pluripotent stem cells (hiPSCs). Wild-type MV strains generally use human signaling lymphocyte activation molecule (SLAM; CD150) as a cellular receptor, while vaccine strains such as the Edmonston strain can use both CD150 and CD46 as receptors. It is not yet known how early in the embryonal differentiation stages these receptors are expressed. We established two hiPSCs (BGU-iPSCs and EMF-iPSCs) which express CD46 and CD150. Both cell types can be infected by MV to form persistent, noncytopathic cell lines that release infectious MV particles. Following MV persistent infection, BGU-iPSCs and EMF-iPSCs remain pluripotent and can differentiate in vitro into the three germ layers. This includes cells expressing the neuronal differentiation markers: NF68 and miRNA-124. Since the MV does not integrate into the cell's genome, it can be utilized as a vehicle to systematically introduce genes into iPSC, to dissect and to define factors regulating lineage differentiation.

Do Male Patients Benefit from Laparoscopic Adjustable Gastric Banding More than Female Patients? A Retrospective Cohort Study.

BACKGROUND: Clinical trials in the field of bariatrics, and specifically laparoscopic adjustable gastric banding (LAGB), have frequently been gender imbalanced, with males representing only 20% of examinees. Long-term gender-oriented results, and specifically quality of life (QOL) parameters, have not been addressed sufficiently. The aim of our study was to examine the long-term gender association with outcome of LAGB including the impact on QOL. METHODS: A retrospective cohort study of patients who underwent LAGB between 2006 and 2014 by a single surgeon was conducted. Data were collected from the hospital registry and a telephone interview that included a standardized questionnaire. Outcomes including BMI reduction, evolution of comorbidities, complications, reoperations, and QOL were compared according to the Bariatric Analysis and Reporting Outcome System (BAROS). RESULTS: Included were 114 males and 127 females, with a mean age of 38.2 years at surgery, and an average post-surgery follow-up of 6.5 years. Similar BMI reduction (p = 0.68) and perioperative complication rates (p = 0.99) were observed. Males had a greater improvement in comorbidities (p < 0.001), less band slippage (p = 0.006), underwent fewer reoperations (p = 0.02), and reported higher QOL scores (p = 0.02) than females. The total BAROS score was significantly higher for males than females (p < 0.001). CONCLUSIONS: LAGB surgery results in better outcomes for male than female patients as measured by the BAROS, despite a similar BMI reduction. Gender-specific outcomes should be taken into consideration in optimizing patient selection and preoperative patient counseling.

Single Port and Conventional Laparoscopy in Colorectal Surgery: Comparison of Two Techniques.

BACKGROUND: Single-incision laparoscopic surgery (SILS) was introduced to further the enhanced outcome of conventional multiport laparoscopy (CML). We compared their short- and long-term outcomes in colorectal surgery. MATERIALS AND METHODS: Retrospective review of patients who underwent elective laparoscopic colorectal surgery during 3-year period. Patients' data, surgery outcomes, and oncological results were compared. RESULTS: Sixty-one patients (33 male, 28 female), mean age 67.4 years, underwent laparoscopic colonic resections: 28 SILS and 33 CML. Twenty-three (37.7%) patients had previous abdominal surgery. There were 19 (31.2%) right, 9 (14.7%) left, and 2 (3.3%) total colectomies, 16 (26.2%) sigmoidectomies, 13 (21.3%) anterior and 2 (3.3%) abdominoperineal resections. Colonic malignancy was a main indication for the surgery in 51 (83.6%) patients. Mean surgery time and postoperative stay were 92.0 minutes and 9 days, respectively. Pathological examination revealed stage I colon cancer in 16 (32%), stage II in 22 (44%), stage III in 10 (20%), and stage IV in 2 (4%) patients. Mean number of retrieved lymph nodes was 19 ± 13.5. No differences were found between groups in demographic data, type of surgery, surgery time and hospital stay, pathological results and tumor staging, and disease-free and overall survivals. In the SILS group, placement of additional trocar was required in 7 (25%) and conversion in 3 (10.7%) cases compared with 1 (3%) case of conversion to formal laparotomy in the CML group. Overall postoperative morbidity was 16.4%. There was no mortality in both the groups. During the study period, 3 patients from the CML group had cancer recurrence. CONCLUSIONS: SILS is a feasible and safe technique compared with CML in terms of surgical and oncological outcomes.

Cell-free deoxyribonucleic acid as a prognostic marker of bowel ischemia in patients with small bowel obstruction.

BACKGROUND: Patients with strangulation small bowel obstruction are at a high risk for serious morbidity and mortality due to ischemic bowel. Measuring serum, cell-free deoxyribonucleic acid levels could help recognize early cell death. Our hypothesis was that small bowel ischemia or necrosis is associated with increases in serum cell-free deoxyribonucleic acid and that recovery is associated with a decrease in cell-free deoxyribonucleic acid levels. METHODS: A prospective cohort study in addition to standard treatment of patients admitted with a diagnosis of small bowel obstruction. The participants were divided into groups depending on the presence of ischemic or necrotic bowel according to operative and clinical outcome. Clinical data and serum-based cell-free deoxyribonucleic acid levels were compared. Cell-free deoxyribonucleic acid levels from these 2 groups also were compared with a third group of healthy controls. RESULTS: In the study, 58 patients were enrolled, and 18 patients (31%) underwent operation. During the operative procedure, ischemic or necrotic bowel was found in 10 cases (17%). Serum levels of cell-free deoxyribonucleic acid at the time of admission in the ischemic/necrotic bowel group were increased compared with patients with well perfused or spontaneously recovered bowel (P = .03). Cell-free deoxyribonucleic acid levels decreased on the day after admission in 88% of the nonoperated patients. No significant differences were found in demographics, medical background, imaging performed, and cause of obstruction nor in clinical admission data. CONCLUSION: Surgeons currently rely on imprecise clinical parameters, including degree of pain, abdominal tenderness, leukocytosis etc to decide when operative intervention is needed. The association of cell-free deoxyribonucleic acid with small bowel obstruction, ischemia, and recovery supports our hypothesis and suggests that this biomarker is a potential surrogate of small bowel perfusion.

[ACADEMIC SURGICAL SERVICES IN A TERTIARY MEDICAL CENTER IN THE NEGEV-DESERT, PERIPHERY OF ISRAEL: IS IT A HYBRID?].

Soroka Medical Center, a major affiliated hospital of the Faculty of Health Sciences in Ben Gurion University of the Negev, serving 1,000,000 citizens in the south part of Israel and is designated as a "peripheral hospital". Herein, we address the factors that influence our high level academic surgical training program with its broad base surgical experience, which focused on the "spirit of Beer Sheba". Should we call our program a hybrid?

Laparoscopic adjustable gastric band removal and outcome of subsequent revisional bariatric procedures: A retrospective review of 214 consecutive patients.

BACKGROUND: Laparoscopic adjustable gastric band (LAGB) removal is required in cases of slippage, erosion, infection, intolerance, or failure in weight loss. The aim of the study was to follow up the patients who underwent band removal and analyze the outcome of subsequent revisional bariatric procedures. PATIENTS AND METHODS: A retrospective review of consecutive patients who underwent LAGB removal during 3.5 years. All patients underwent a phone interview in early 2015. Patients were divided to three groups following band removal: without additional surgery, laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en Y gastric bypass (LRYGB), and Redo LAGB(Re-LAGB). Outcome of different revisional procedures was compared according to causes and symptoms before band removal, patient satisfaction, weight loss, quality of life (QOL) questionnaire, and the bariatric analysis and reporting outcome system II (BAROSII) score. RESULTS: Overall 214 patients (73.8% females) with mean age of 41.9 years were enrolled in the study. The mean time between LAGB placement and removal was 81.0 months. Mean % estimated weight loss (%EWL) was 29.6 at time of band removal. There was no difference between groups in patient age, gender, BMI before LAGB, and most co-morbidities. Patients with 1-5 outpatient visits preferred additional surgery. Patients suffering from vomiting from 1 to 10 times per week preferred revision as LSG or LRYGB. Patients with lower BAROS score underwent LSG or LRYGB. Most of the patients with band intolerance underwent conversion to another bariatric procedure, while patients with band erosion and infected band preferred Re-LAGB. Most of the patients without band gained weight. There was a significant improvement in %EWL (39.9 vs 29.6), QOL (1.08 vs 0.07), and BAROS(2.82 vs-0.11) in patients who underwent additional bariatric surgery before and after band removal irrespective of surgery type. CONCLUSIONS: Patient selection for different revisional bariatric procedures after LAGB removal is a main point for surgery success. This results in high patient satisfaction, EWL, and QOL. All options (Re-LAGB, LSG, LRYGB) are feasible and safe.

Diagnostic value of laparoscopy, abdominal computed tomography, and ultrasonography in acute appendicitis.

BACKGROUND: The most efficient approach to diagnosis of acute appendicitis (AA) continues to be a challenge. We sought to determine diagnostic accuracy, sensitivity, and specificity of computed tomography (CT), ultrasonography, and laparoscopy and compared benefits and advantages in patients with suspected AA. PATIENTS AND METHODS: A retrospective review of all patients who had laparoscopic surgery between January 2000 and December 2009 was conducted. Preoperative information, surgery results, and outcomes were compared. RESULTS: Of 887 laparoscopic procedures performed for suspected AA, 254 (29%) patients had preoperative imaging: 171 CT scans and 83 ultrasound (US) scans. Overall, 754 patients underwent laparoscopic appendectomy (LA), and 133 underwent diagnostic laparoscopy (DL). DL was negative in 23 patients. The sensitivity of LA was higher than that of CT (98% versus 94%), whereas the specificity of LA was higher than that of CT and US in complicated appendicitis and in women. Complicated AA was significantly less common in patients who underwent laparoscopic surgery compared with patients evaluated by preoperative CT. Comparing the kappa value between the preoperative diagnosis by imaging and DL, a weak agreement was found (κ=0.234 ± 0.057). CONCLUSIONS: Laparoscopy achieves early and accurate diagnosis of AA and can reduce the incidence of perforated appendicitis. Abdominal CT remains a valuable diagnostic tool. DL is useful in the early stages of the diagnostic work-up and avoids unnecessary exposure to radiation of the abdomen and pelvis in young women.

Endoscopic self-expanding metal stents for acute colonic obstruction.

The current study presents our experience with the introduction of self-expanding metal stents (SEMS) and assesses success rate, clinical outcomes, and complications. We conducted a historical cohort study reviewing endoscopic SEMS insertions between 2000 and 2010. Overall, 51 patients underwent stent insertion: 38 with an emergent procedure and 13 with a semielective procedure. SEMS was inserted in 27 men and 24 women with a mean age of 68.9 years. Colonic malignancy was the cause of obstruction in all patients. The tumors were localized in the rectosigmoid in 33 (64.7%), in the left colon in 16 (31.4%), and in the right colon in two cases (3.9%). Endoscopic SEMS insertion was technically successful in 68.4 per cent of patients in an emergency and in 84.6 per cent of patients in a semielective setting. Successful stent insertion allowed a "bridge to surgery" in 23 and palliative care in 14 patients. Stent migration occurred in three, obstruction in two, and bowel perforation in three cases. Nineteen patients in the emergent group underwent a subsequent successful semielective colonic resection within 8.1 days (range, 2 to 30 days) of stent insertion. There were two cases (11.1%) of major and four cases (22.2%) of minor postoperative complications in this series. No anastomotic leaks were observed. Mean postoperative hospitalization was 10.1 days (range, 5 to 45 days). Endoscopic stent insertion is a relatively simple procedure providing an effective first-line treatment for relief of symptoms of acute malignant colorectal obstruction, preventing acute perforation, and serving either as a preoperative procedure (allowing lower morbidity semielective surgery) or as palliative care.

Management of gastric perforations during laparoscopic gastric banding.

BACKGROUND: Gastric perforations are one of the intraoperative complications of laparoscopic gastric banding (LAGB). Delayed diagnosis can increase the mortality and morbidity rates. METHODS: Retrospective analysis of surgery outcome and long-term follow-up of the patients with gastric perforations during primary LAGB and revisional band procedures was performed. RESULTS: Twenty-four patients with gastric perforations were identified during 15 years of LAGB surgeries. Half of these had primary LAGB and half had revisional procedures (five emergent and seven elective). Gastric tear was found at surgery in 19 patients; the band was preserved and LAGB was completed in 18 of these. Five patients had delayed diagnosis and underwent re-exploration 24-72 h after surgery. During the surgery, 23 anterior, 8 posterior, 1 esophageal, and 1 small bowel tears were found. Laparoscopic repair was successful in 19 (83%) cases. The mean surgery time and mean hospital stay were 56.3 min and 7.8 days, respectively. Morbidity and mortality rates were 25 and 4.1%, respectively. Two patients underwent later band replacement following removal. Band erosion was observed in one patient. At least 17 patients had no complications during mean follow-up of 52.2 months. CONCLUSIONS: Band preservation is recommended following primary repair of gastric tear. Early intra- and postoperative diagnosis of gastric tear in LAGB is essential for successful management of this iatrogenic injury and decreases occurrence of complications.

[Free abdominal air in the emergency room--a diagnostic dilemma].

The current article revolves upon the challenge of diagnosing free peritoneal air in an abdominal X-ray. We present an 80 year old lady who was admitted due to abdominal pain and vomiting. On an acute abdomen XR series, a small amount of free air was suspected, but this was inconclusive. This article focuses upon the complexity of diagnosing abdominal free air Acute abdomen radiography is an essential tool in the evaluation of an acute abdomen, and research has shown that an acute abdominal X-ray series appropriately conducted and interpreted by qualified experts can show as little as 1 cc of free air in the peritoneum. Other studies, on the other hand, have shown that 30-50% of patients with bowel perforation, especially in the elderly population, will not show signs of free air on X-rays. We believe that the proper evaluation and diagnosis of free air involves a methodical approach. First one should begin with an acute abdominal X-ray series. It is advised to have the patient stand or lie in the left decubitus position for 10-15 minutes before the X-rays are conducted. Use of high resolution monitors to enhance the visual acuity and consulting an expert radiologist can help when in doubt. If one is still not sure, it is recommended to perform a CT scan, which is the gold standard for detecting free peritoneal air.

Slit versus non-slit mesh placement in total extraperitoneal inguinal hernia repair.

BACKGROUND: The goal of the present research was to study patients who underwent laparoscopic total extraperitoneal repair using slit and non-slit mesh placement. METHODS: Patients who underwent laparoscopic inguinal hernia repair in our hospital between 2005 and 2009 were interviewed and examined. Surgery outcome, hernia recurrence, postoperative pain and time to return to normal physical activities, and surgery satisfaction were compared. RESULTS: During the study period 389 consecutive patients underwent laparoscopic groin hernia repair: 387 by the total extraperitoneal (TEP) approach and 2 by the TAPP approach. Six of the TEP patients were converted to TAPP. Eighty-seven patients in the TEP group had slit mesh placement and 300 had non-slit mesh placement. Mean follow-up was 36 months (range: 6-66 months). At follow-up, 387 patients responded to a request for interview and 277 were examined. The overall recurrence rate was 4.7%, the incidence of constant postoperative pain was 1.3%, the presence of permanent testicular pain was 2.8%, and patient satisfaction with the surgery was 94.5%. A significantly lower recurrence rate was found in the slit mesh group than in the non-slit group (0.6% versus 5.9%; p < 0.003). There was no difference in the length of time until return to normal activities, patient satisfaction, and postoperative pain between the groups. Surgery time and the occurrence of testicular pain were significantly greater in the anatomic group. CONCLUSIONS: Total extraperitoneal inguinal hernia repair with slit mesh placement is a safe technique with a very low recurrence rate and is superior to non-slit mesh positioning.