European Journal of Gastroenterology & Hepatology, 2018
Background The prevalence of obesity is as high as one-third of the adult population in the ultra... more Background The prevalence of obesity is as high as one-third of the adult population in the ultrasound. Obese patients operated for rectal cancer are less likely to undergo sphincter-preserving surgery, and have an increased morbidity and mortality. We aim to report the outcomes of transanal-endoscopic-microsurgery (TEM) in obese patients with benign and malignant neoplasms. Materials and methods An analysis was carried out of all patients undergoing TEM at a single institution between 2004 and 2015. Clinical, demographic, and pathologic data were analyzed in respect to BMI; a dichotomous variable was created categorizing the patients in this retrospective case series as either obese (BMI ≥ 30) or nonobese (BMI < 30). Results Of the 158 patients who underwent TEM during the study period, 51 (32%) were obese and 107 (68%) were nonobese. No significant differences were found in terms of patients' demographics and tumor characteristics. There were no significant differences in operative time [105 min (range: 75-170) and 98 (range: 56-170), respectively, P = 0.2], hospital length of stay [3 days (range: 2-6) and 4 (range: 2-12), respectively, P = 0.48], or complication rates (20 and 23%, respectively, P = 0.68). Conclusion TEM is a safe procedure for rectal neoplasms in the obese population. We found no difference in surgical time and completeness of specimen resection, and no increase in complications or length of stay in the hospital in obese versus nonobese patients. As for selected high risk patients, the TEM may be of benefit in obese patients with T1/T2N0M0 rectal cancer. Eur J
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 2016
Diverting ileostomy is recommended in patients undergoing neoadjuvant chemoradiotherapy and low a... more Diverting ileostomy is recommended in patients undergoing neoadjuvant chemoradiotherapy and low anterior resection for low-rectal cancer. Prior to ileostomy reversal, water-soluble enema is performed to assess the low colorectal anastomosis. The aim of this study was to assess whether performance of routine water-soluble enema prior to ileostomy takedown is necessary. All mid-low rectal cancer patients who underwent low anterior resection with temporary diverting ileostomy after neoadjuvant chemoradiotherapy, between 2006 and 2013, were identified, retrospectively. The colorectal anastomosis prior to ileostomy takedown was evaluated by digital rectal exam, rigid proctoscopy, and water-soluble enema. The rectal exam and proctoscopy findings were compared to those of the water-soluble enema. The efficacy of routine water-soluble enema was assessed. Three hundred and twelve (184 male) patients (mean age 62.2 ± 17 years) met the inclusion criteria. Ten patients (3 %) experienced a conta...
As we begin to consider the role of the various humoral effectors and cellular synthesized mediat... more As we begin to consider the role of the various humoral effectors and cellular synthesized mediators of the human Host Defense Response in the evolution of various organ failure states after injury and sepsis, it becomes clear that a methodology needs to be established for the quantification of severity in patients with these disease processes. The use of largely heuristic classification schemes has not proved sufficiently precise enough to allow these types of correlation to be explored [1–6]. The sepsis syndrome [7] which has been recently advocated as a criteria for the initiation of a variety of therapeutic methodologies is insufficiently precise. It allows trauma patients with non-septic inflammatory responses to injury be included in the syndrome and does not offer true quantification, but merely a threshold for the initiation of therapeutic modalities. Also, the use of trauma scoring systems based on some simple multiplicative factor applied to types of injury which are then summed to produce a severity index such as used in the abbreviated injury score (AIS) [8] or the injury severity score (ISS) [1] have also not proved particularly useful, since there is a wide variability in the scores based on anatomic classifications of trauma intensity.
Background Local excision for early rectal cancer has low morbidity and good functional results. ... more Background Local excision for early rectal cancer has low morbidity and good functional results. Its use is limited by the inability to assess regional lymph nodes and by the uncertainty of oncologic outcome. Methods We conducted a retrospective chart review of all patients who underwent local excision of early rectal cancer in two colorectal units between 1995 and 2007. The retrieved and analyzed data were patient age and gender, tumor size, tumor distance from the anal verge, tumor differentiation, and additional treatment. Results There were 42 patients with T1 rectal cancer: 24 underwent transanal endoscopic microsurgery and 18 had a transanal excision. The surgical margins were free of tumor in 39 patients (93%), they were involved by tumor in one (2%) and margin status was unclear in two (5%). Seven patients (16%) had postoperative complications. There was no postoperative mortality. The mean hospital stay was 67 h. Thirty-nine patients (93%) were followed up for 57 months (mean). Two patients had local recurrence, at 7 and 41 months post-surgery. They had a tumor that invaded into the lower third of the submucosa, sm3. Both received chemoradiotherapy, and underwent an abdominoperineal resection and a low anterior resection. One of them died of metastatic disease 13 months later and the other is alive with no evidence of disease. Another two patients had salvage low anterior resection, one for suspected local recurrence and one for lymphovascular invasion: the specimens were tumor free. Six patients died of unrelated causes. Conclusions Local excision of early rectal cancer is a feasible and acceptable alternative to radical resection. It has low complication and recurrence rates and a short postoperative hospital stay.
International journal of surgery (London, England), Jan 19, 2016
Local excision is the treatment of choice for large benign rectal lesions. Transanal endoscopic m... more Local excision is the treatment of choice for large benign rectal lesions. Transanal endoscopic microsurgery is recommended. The excision of large lesions >4 cm has been previously described. We report our series of lesions >5 cm that have been excised via the transanal endoscopic microsurgery. Patients who underwent transanal endoscopic microsurgery for rectal tumors, between the years 2002-2012, were identified. Patients with tumors greater than 5 cm consisted the study group. Tumor diameter was determined based on fresh specimen measurements. Data pertaining to patients and tumor characteristics, operative and histopathology findings, postoperative outcomes were collected. Local recurrence and effects on anal sphincter function were assessed. Twenty five patients (14 female) with mean age of 70.3 ± 10.1 years, met the inclusion criteria. The mean tumor size was 5.7 ± 0.9 cm. The median distance from anal verge was 8 cm (range 1-17). Preoperative biopsy of the rectal tumor r...
The Israel Medical Association journal : IMAJ, 2005
BACKGROUND Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical ... more BACKGROUND Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. OBJECTIVES To evaluate the long-term functional outcome of patients who underwent this surgical procedure. METHODS We performed this observational study in 174 consecutive patients: 146 with UC and 28 with FAP. The patients, 91 males and 83 females with a mean age of 34.1+/-10.6 years (range 6-67 years), underwent the procedure between January 1984 and January 2004 (mean follow-up 64.8 months, range 1-240 months). The indications for surgery were intractable disease in 124 patients (71%), dysplasia in 36 (21%), severe bleeding in 8 (5%), and perforation in 6 (3%). RESULTS A protective ileostomy was performed in 140 patients (96%) with UC and 12 (43%) with FAP. An urgent three-stage procedure was necessary in 14 patients (8.4%). A mucosal proctectomy was performed in 94 (54%), and a double staplin...
Transanal endoscopic microsurgery is part of the colorectal surgeons' armamentarium for over ... more Transanal endoscopic microsurgery is part of the colorectal surgeons' armamentarium for over 2 decades. Since its first implementation for the resection of benign and T1 malignant lesions in the rectum several new indications were developed and it carries additional promise for further extension in upcoming years. Herein we review the technique, its current indications, novel implications, and future perspectives.
Transanal endoscopic microsurgery has recently gained acceptance as an alternative minimally inva... more Transanal endoscopic microsurgery has recently gained acceptance as an alternative minimally invasive surgical technique for the curative management of large rectal adenomas and selected early rectal carcinomas. To analyze our 8 year experience using TEM for the management of rectal cancer. Local resection by TEM was performed in patients with benign tumors and early rectal cancer. In addition, selected patients with T2 and T3 rectal cancers who were either medically unfit or unwilling to undergo radical surgery were also treated with this modality. Radical surgery was offered to all patients with incomplete tumor excision by TEM. Overall, 116 TEM operations for rectal tumors were carried out between 1995 and 2003, including 74 patients with rectal adenomas and 42 patients with rectal carcinomas. In 25 patients, TEM successfully removed all T1 tumors with clear tumor margins. Fourteen patients had T2 cancer and 3 of them (21%) required additional radical surgery due to incomplete ex...
PURPOSE: The use of transanal endoscopic microsurgery for local excision of rectal cancer has rec... more PURPOSE: The use of transanal endoscopic microsurgery for local excision of rectal cancer has recently gained wide acceptance as a valid and safe alternative for the surgical treatment of T1 tumors. The adequacy of such treatment for T2 tumors, however, is still controversial. This study was designed to evaluate our results with local excision of T2 cancers. METHODS: Patients with T2 cancer admitted to our hospital between 1995 and 2005 were offered surgery by transanal endoscopic microsurgery if found medically unfit or were unwilling to undergo radical surgery. Patients who were preoperatively staged as T1 tumor but were found to be pathologically T2 also were included. RESULTS: Overall, we performed 59 transanal endoscopic microsurgery operations for rectal cancers, of which 21 were for T2 cancers. In 16 (76 percent) of the T2 patients, the tumors were completely removed with clear margins by transanal endoscopic microsurgery and no additional surgery was performed, except for 2 ...
The management of penetrating abdominal stab wounds has been the subject of continued reappraisal... more The management of penetrating abdominal stab wounds has been the subject of continued reappraisal and controversy. In the present study a novel method which combines the use of diagnostic laparoscopy and DPL, termed laparoscopic diagnostic peritoneal lavage (L-DPL) is described Five trauma patients with penetrating injuries to the lower chest or abdomen were included. Standard videoscopic equipment is utilized for the laparoscopic trauma evaluation of the injured patient. When no significant injury is detected, the videoscope is withdrawn and 1000 mL of normal saline is infused through the abdominal trochar into the peritoneal cavity, and the effluent fluid studied for RBCs, WBC, amylase debry, bile as it is uced in regular diagnostic peritoneal lavage Laparoscopic peritoneal lavage (L-DPL) was then performed and proved to be negative in all 5 patients. RBC lavage counts above 100,000/mcrl were not considered as a positive lavage result, because the bleeding source was directly obse...
Bleeding from the small intestine is still a very difficult diagnostic problem, even with the mos... more Bleeding from the small intestine is still a very difficult diagnostic problem, even with the most advanced diagnostic procedures. This report suggests the use of intraoperative endoscopy of the small intestine by the introduction of a colonoscope through the mouth. The whole length of the small intestine can be invaginated on the advancing colonoscope and even intramural lesions can be
Distal margin &amp;amp;amp;amp;amp;amp;gt;1 cm provides an oncologic safety in low-lying rect... more Distal margin &amp;amp;amp;amp;amp;amp;gt;1 cm provides an oncologic safety in low-lying rectal cancers. We evaluated the accuracy of frozen section (FS) examination in estimating distal margins, and its impact on intraoperative decision making regarding restorative proctectomy. Retrospective study of patients who underwent surgery for adenocarcinoma of the mid or lower rectum during 2001-2010 and for whom a distal margin specimen was examined intraoperatively by FS, to confirm microscopically free margins. Intraoperative findings, and frozen and final paraffin section findings were retrieved from patient charts. A distal margin of ≤1 cm was compared with &amp;amp;amp;amp;amp;amp;gt;1 cm, for free margins at final pathology and local recurrence (LR). The impact of a distal margin ≤5 mm was also assessed. The impact of FS on intraoperative decision making, in patients who did and did not receive preoperative chemoradiotherapy, was assessed. The mean age of the 63 patients studied was 66.4 ± 11.8 years, and median tumor distance from the anal verge 6 cm (range 1-10 cm). Seven patients underwent abdominoperineal resection, 54 anterior resection, and two Hartman procedures. FS sensitivity and specificity were 83% and 98%, respectively. Accuracy of FS was high for the 41 patients treated with preoperative chemoradiotherapy, and the 22 who were not. Distal margin &amp;amp;amp;amp;amp;amp;gt;5 mm at FS examination ensured a free margin at final pathology. LR rate was comparable between patients with distal margin &amp;amp;amp;amp;amp;amp;gt;10 mm and ≤10 mm, 8% vs 11%, P = 0.65. FS examination may help determine free distal margin and consequently, in selected cases, may facilitate a restorative procedure in patients with low rectal cancer.
Rectal duplication cyst is a rare entity that accounts for approximately 4% of all alimentary tra... more Rectal duplication cyst is a rare entity that accounts for approximately 4% of all alimentary tract duplications. To the best of our knowledge, the presented cases are the first reports in the English literature of rectal duplication cyst resection by transanal endoscopic microsurgery. We present two patients; both are 41-year-old women with a palpable rectal mass. Workup revealed a submucosal posterior mass that was then resected by transanal endoscopic microsurgery. The pathology report described cystic lesions with squamous and columnar epithelium and segments of smooth muscle. These findings were compatible with rectal duplication cyst. Our limited experience showed good results with minimal morbidity and mortality for resection of rectal duplication cysts of limited size with no evidence of malignancy.
Transanal endoscopic microsurgery (TEM) was originally designed for local endoscopic excision of ... more Transanal endoscopic microsurgery (TEM) was originally designed for local endoscopic excision of benign and low-grade mucosal rectal lesions through an endoscopic system. The procedure is particularly challenging for submucosal and retrorectal lesions, as the tumor margins are not well defined. To investigate patient and surgical characteristics of TEM as a treatment for submucosal rectal and retrorectal lesions. All the patients in our department of general surgery who underwent TEM for a submucosal rectal or retrorectal lesion, between the years 2001 and 2011, were identified. Their charts were reviewed and data pertaining to demographic characteristics and medical history, including tumor characteristics, were collected. Operative notes and histopathology reports were also reviewed. The adequacy of the tumor resection, that ism attainment of free margins, endoscopic completion of the procedure, and perioperative complications, were assessed. Fifteen patients (5 females, 10 males), mean age 53.9 ± 16.9 years, were identified. The main indications for surgery were gastrointestinal stromal tumor (5 patients) and tailgut or duplication cyst (4 patients). All procedures were completed endoscopically. The median distance from the anal verge was 7.3 cm (range, 5 to 10 cm), and the mean diameter of the tumors was 3 ± 1.1 cm. The one patient in whom the margins presented tumoral involvement underwent repeated TEM. No intraoperative complications were reported. The postoperative complication rate was 13.3%, and the mean length of hospital stay was 1.85 ± 1.77 days. TEM for retrorectal and submucosal rectal lesions is feasible and safe. A remarkably low morbidity rate and limited surgical injury favor TEM in selected patients.
Compared with traditional rectal resection, transanal endoscopic microsurgery (TEM) is faster and... more Compared with traditional rectal resection, transanal endoscopic microsurgery (TEM) is faster and safer. This retrospective study sought to assess the efficacy of TEM for lesions located in the upper rectum, ≥10 cm from the anal verge. Data from all patients who underwent TEM for rectal lesions ≥10 cm from the anal verge between 2001 and 2010 at two medical centers in Israel were retrospectively analyzed. The study group comprised 96 patients (57 men, 39 women) who underwent 99 TEM procedures. Collected data included patient demographics, tumor characteristics, indications for surgery, operative findings and details, postoperative outcomes, and histopathologic findings. Long-term outcomes including local recurrence (LR) for benign lesions and LR and overall survival (OS) for malignant lesions were calculated. Categorical variables were calculated by frequency tables, and linear variables were represented by averages and standard deviation or median with the spread of variables. Survival and LR analysis was performed by Kaplan-Meier and Cox regression methods. The mean tumor distance from the anal verge was 11.3 ± 2 cm and the median tumor size was 2 cm. Early postoperative outcomes were favorable, and no early postoperative mortality was reported. The postoperative morbidity rate was 10%. For long-term outcomes, in the subgroup with benign lesions, after a median follow-up of 8.7 years, the LR rate was 5.1%. In the group with malignant lesions, LR and OS rates were 6.9 and 87%, respectively. TEM for upper rectal lesions is feasible and may be safe in selected cases. Low morbidity rate, shorter operative time and length of stay, no mortality events, and favorable long-term outcomes support the use of TEM for the treatment of lesions in the upper rectum.
We evaluated the role of intraoperative frozen section (FS) in the surgical management of solitar... more We evaluated the role of intraoperative frozen section (FS) in the surgical management of solitary thyroid nodules, as its true value is a subject of some controversy. We reviewed the records of 206 consecutive patients operated on for solitary thyroid nodules. All patients had undergone both preoperative fine-needle aspiration (FNA) and intraoperative FS. The diagnostic findings of FNA cytology and FS histology were compared with the final histological results. There were 61 patients with cancer and 145 with various benign conditions. The sensitivity and specificity of FNA were 78.1% and 96.5%, respectively, demonstrating an overall accuracy of 91.3%. The sensitivity, specificity, and accuracy rates for FS were 83.3%, 95.2%, and 91.7%, respectively. FS altered the operative decision in 14 patients, but correctly so in only 8 patients. Correlated with FNA cytology, the yield of FS in assisting in the intraoperative decision making was 1.8%, 3.4%, and 5.2% for benign, malignant, and suspicious cytology, respectively. When the results of FNA and FS are interpreted as either benign or malignant, both are highly accurate predictors of the pathological nature of the nodule. However, the findings of the present study do not support the use of FS in the surgical management of solitary thyroid nodules, regardless of FNA cytology.
Retrorectal tumors are an uncommon pathological entity. Their clinical importance arises from the... more Retrorectal tumors are an uncommon pathological entity. Their clinical importance arises from their occasional malignant nature or malignant transformation. The treatment of choice for most presacral tumors is surgical excision. The approach depends upon the upper limit of the lesion and the presumptive pathology. We reviewed the main features of these tumors with emphasis on transanal endoscopic microsurgery (TEM) as a viable surgical approach for the treatment of the lesions, undertaken in our institution. We present our small case series, consisting of six patients with retrorectal lesions who underwent local excision via TEM. Early and late postoperative outcomes are presented. TEM for retrorectal lesions appears to be a feasible and safe approach. A remarkably low morbidity favors TEM in selected patients.
Intussusception is the most common cause of bowel obstruction in children, but it is a very rare ... more Intussusception is the most common cause of bowel obstruction in children, but it is a very rare cause of bowel obstruction in the elderly. Diagnosis is based on a high index of suspicion, complete anamnestic recall, physical examination, and imaging modalities. We find abdominal CT scans to be highly sensitive and accurate for making the diagnosis.
Journal of Laparoendoscopic & Advanced Surgical Techniques, 2013
The benefits of transanal endoscopic microsurgery (TEM) for the excision of benign and low-grade ... more The benefits of transanal endoscopic microsurgery (TEM) for the excision of benign and low-grade malignant lesions in the low and middle rectum are well recognized. This study examined the feasibility and safety of a repeated TEM procedure. Patients who underwent a repeat TEM for excision of rectal lesions, either for involved resection margins or for local recurrence, between the years 2000 and 2010, were identified. Rectal lesion characteristics were retrieved. Mean operative times, length of hospital stay, and intra- and postoperative complications were compared between primary and repeated procedures. The postoperative histopathology reports were reviewed, and the adequacy of resection was determined. All patients completed a questionnaire based on the Wexner score for anal sphincter function evaluation. Fourteen patients (3 female, 11 male) underwent a repeat TEM operation during the study period. All procedures were completed endoscopically. Indications for repeated TEM were involved margins in 12 patients and recurrence of benign tumor in 2. Mean operative time, mean length of hospital stay, and rate of postoperative complications were similar for primary and repeated TEM procedures (62.5 ± 17 versus 55 ± 23 minutes, P=.181; 1.7 ± 1.3 versus 1.7 ± 1.12 days, P=.99; and 35.7% versus 21.4%, P=.66, respectively). The Wexner score was comparable at baseline and after the first and the second TEM procedures (1.5 ± 2.3, 1.5 ± 2.3, and 3.3 ± 3.1, respectively; P=.188). No cases of fecal incontinence following a repeat TEM were documented. Repeated TEM is feasible and safe and may be appropriate for selected patients.
Preoperative stoma site marking and counseling aim to improve patients&amp;amp;amp;amp;amp;am... more Preoperative stoma site marking and counseling aim to improve patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; rehabilitation and adaptation to a new medical condition. Objective studies are needed to provide evidence of the impact of care by stoma therapists. Key quality indicators include patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; quality of life, independence, and complication rates as affected by the variable modes of stoma site marking and planning. The aim of this study was to evaluate the impact of preoperative stoma site marking on patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; quality of life, independence, and complication rates. : A validated stoma quality-of-life questionnaire was used as the main assessment tool. Complications were noted on regular postoperative visits. This is a single-center, clinical study. The study was conducted at the Rambam Health Care Campus in Haifa, Israel. Rambam Health Care Campus is a tertiary university hospital. All patients who underwent an elective stoma creation between 2006 and 2008 were included. Evaluated parameters included demographics, stoma type, marking status, complication rates, quality of life, and independence parameters. : One hundred five patients (60 men and 45 women) were included, of whom 52 (49.5%) were preoperatively marked and 53 (50.5%) were not marked. Sixty stomas (57%) were permanent, and 45 (43%) stomas were temporary. The quality of life of patients whose stoma sites were preoperatively marked was significantly better than that of the unmarked patients (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05 in 18 of 20 items), their independence parameters were significantly better, and their complication rates significantly lower. All of these results were significant irrespective of the stoma type. Preoperative stoma site marking is crucial for improving patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; postoperative quality of life, promoting their independence, and reducing the rates of postoperative complications. The role of the enterostomal therapist is very important in the ostomates&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; pre- and postoperative care.
European Journal of Gastroenterology & Hepatology, 2018
Background The prevalence of obesity is as high as one-third of the adult population in the ultra... more Background The prevalence of obesity is as high as one-third of the adult population in the ultrasound. Obese patients operated for rectal cancer are less likely to undergo sphincter-preserving surgery, and have an increased morbidity and mortality. We aim to report the outcomes of transanal-endoscopic-microsurgery (TEM) in obese patients with benign and malignant neoplasms. Materials and methods An analysis was carried out of all patients undergoing TEM at a single institution between 2004 and 2015. Clinical, demographic, and pathologic data were analyzed in respect to BMI; a dichotomous variable was created categorizing the patients in this retrospective case series as either obese (BMI ≥ 30) or nonobese (BMI < 30). Results Of the 158 patients who underwent TEM during the study period, 51 (32%) were obese and 107 (68%) were nonobese. No significant differences were found in terms of patients' demographics and tumor characteristics. There were no significant differences in operative time [105 min (range: 75-170) and 98 (range: 56-170), respectively, P = 0.2], hospital length of stay [3 days (range: 2-6) and 4 (range: 2-12), respectively, P = 0.48], or complication rates (20 and 23%, respectively, P = 0.68). Conclusion TEM is a safe procedure for rectal neoplasms in the obese population. We found no difference in surgical time and completeness of specimen resection, and no increase in complications or length of stay in the hospital in obese versus nonobese patients. As for selected high risk patients, the TEM may be of benefit in obese patients with T1/T2N0M0 rectal cancer. Eur J
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 2016
Diverting ileostomy is recommended in patients undergoing neoadjuvant chemoradiotherapy and low a... more Diverting ileostomy is recommended in patients undergoing neoadjuvant chemoradiotherapy and low anterior resection for low-rectal cancer. Prior to ileostomy reversal, water-soluble enema is performed to assess the low colorectal anastomosis. The aim of this study was to assess whether performance of routine water-soluble enema prior to ileostomy takedown is necessary. All mid-low rectal cancer patients who underwent low anterior resection with temporary diverting ileostomy after neoadjuvant chemoradiotherapy, between 2006 and 2013, were identified, retrospectively. The colorectal anastomosis prior to ileostomy takedown was evaluated by digital rectal exam, rigid proctoscopy, and water-soluble enema. The rectal exam and proctoscopy findings were compared to those of the water-soluble enema. The efficacy of routine water-soluble enema was assessed. Three hundred and twelve (184 male) patients (mean age 62.2 ± 17 years) met the inclusion criteria. Ten patients (3 %) experienced a conta...
As we begin to consider the role of the various humoral effectors and cellular synthesized mediat... more As we begin to consider the role of the various humoral effectors and cellular synthesized mediators of the human Host Defense Response in the evolution of various organ failure states after injury and sepsis, it becomes clear that a methodology needs to be established for the quantification of severity in patients with these disease processes. The use of largely heuristic classification schemes has not proved sufficiently precise enough to allow these types of correlation to be explored [1–6]. The sepsis syndrome [7] which has been recently advocated as a criteria for the initiation of a variety of therapeutic methodologies is insufficiently precise. It allows trauma patients with non-septic inflammatory responses to injury be included in the syndrome and does not offer true quantification, but merely a threshold for the initiation of therapeutic modalities. Also, the use of trauma scoring systems based on some simple multiplicative factor applied to types of injury which are then summed to produce a severity index such as used in the abbreviated injury score (AIS) [8] or the injury severity score (ISS) [1] have also not proved particularly useful, since there is a wide variability in the scores based on anatomic classifications of trauma intensity.
Background Local excision for early rectal cancer has low morbidity and good functional results. ... more Background Local excision for early rectal cancer has low morbidity and good functional results. Its use is limited by the inability to assess regional lymph nodes and by the uncertainty of oncologic outcome. Methods We conducted a retrospective chart review of all patients who underwent local excision of early rectal cancer in two colorectal units between 1995 and 2007. The retrieved and analyzed data were patient age and gender, tumor size, tumor distance from the anal verge, tumor differentiation, and additional treatment. Results There were 42 patients with T1 rectal cancer: 24 underwent transanal endoscopic microsurgery and 18 had a transanal excision. The surgical margins were free of tumor in 39 patients (93%), they were involved by tumor in one (2%) and margin status was unclear in two (5%). Seven patients (16%) had postoperative complications. There was no postoperative mortality. The mean hospital stay was 67 h. Thirty-nine patients (93%) were followed up for 57 months (mean). Two patients had local recurrence, at 7 and 41 months post-surgery. They had a tumor that invaded into the lower third of the submucosa, sm3. Both received chemoradiotherapy, and underwent an abdominoperineal resection and a low anterior resection. One of them died of metastatic disease 13 months later and the other is alive with no evidence of disease. Another two patients had salvage low anterior resection, one for suspected local recurrence and one for lymphovascular invasion: the specimens were tumor free. Six patients died of unrelated causes. Conclusions Local excision of early rectal cancer is a feasible and acceptable alternative to radical resection. It has low complication and recurrence rates and a short postoperative hospital stay.
International journal of surgery (London, England), Jan 19, 2016
Local excision is the treatment of choice for large benign rectal lesions. Transanal endoscopic m... more Local excision is the treatment of choice for large benign rectal lesions. Transanal endoscopic microsurgery is recommended. The excision of large lesions >4 cm has been previously described. We report our series of lesions >5 cm that have been excised via the transanal endoscopic microsurgery. Patients who underwent transanal endoscopic microsurgery for rectal tumors, between the years 2002-2012, were identified. Patients with tumors greater than 5 cm consisted the study group. Tumor diameter was determined based on fresh specimen measurements. Data pertaining to patients and tumor characteristics, operative and histopathology findings, postoperative outcomes were collected. Local recurrence and effects on anal sphincter function were assessed. Twenty five patients (14 female) with mean age of 70.3 ± 10.1 years, met the inclusion criteria. The mean tumor size was 5.7 ± 0.9 cm. The median distance from anal verge was 8 cm (range 1-17). Preoperative biopsy of the rectal tumor r...
The Israel Medical Association journal : IMAJ, 2005
BACKGROUND Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical ... more BACKGROUND Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. OBJECTIVES To evaluate the long-term functional outcome of patients who underwent this surgical procedure. METHODS We performed this observational study in 174 consecutive patients: 146 with UC and 28 with FAP. The patients, 91 males and 83 females with a mean age of 34.1+/-10.6 years (range 6-67 years), underwent the procedure between January 1984 and January 2004 (mean follow-up 64.8 months, range 1-240 months). The indications for surgery were intractable disease in 124 patients (71%), dysplasia in 36 (21%), severe bleeding in 8 (5%), and perforation in 6 (3%). RESULTS A protective ileostomy was performed in 140 patients (96%) with UC and 12 (43%) with FAP. An urgent three-stage procedure was necessary in 14 patients (8.4%). A mucosal proctectomy was performed in 94 (54%), and a double staplin...
Transanal endoscopic microsurgery is part of the colorectal surgeons' armamentarium for over ... more Transanal endoscopic microsurgery is part of the colorectal surgeons' armamentarium for over 2 decades. Since its first implementation for the resection of benign and T1 malignant lesions in the rectum several new indications were developed and it carries additional promise for further extension in upcoming years. Herein we review the technique, its current indications, novel implications, and future perspectives.
Transanal endoscopic microsurgery has recently gained acceptance as an alternative minimally inva... more Transanal endoscopic microsurgery has recently gained acceptance as an alternative minimally invasive surgical technique for the curative management of large rectal adenomas and selected early rectal carcinomas. To analyze our 8 year experience using TEM for the management of rectal cancer. Local resection by TEM was performed in patients with benign tumors and early rectal cancer. In addition, selected patients with T2 and T3 rectal cancers who were either medically unfit or unwilling to undergo radical surgery were also treated with this modality. Radical surgery was offered to all patients with incomplete tumor excision by TEM. Overall, 116 TEM operations for rectal tumors were carried out between 1995 and 2003, including 74 patients with rectal adenomas and 42 patients with rectal carcinomas. In 25 patients, TEM successfully removed all T1 tumors with clear tumor margins. Fourteen patients had T2 cancer and 3 of them (21%) required additional radical surgery due to incomplete ex...
PURPOSE: The use of transanal endoscopic microsurgery for local excision of rectal cancer has rec... more PURPOSE: The use of transanal endoscopic microsurgery for local excision of rectal cancer has recently gained wide acceptance as a valid and safe alternative for the surgical treatment of T1 tumors. The adequacy of such treatment for T2 tumors, however, is still controversial. This study was designed to evaluate our results with local excision of T2 cancers. METHODS: Patients with T2 cancer admitted to our hospital between 1995 and 2005 were offered surgery by transanal endoscopic microsurgery if found medically unfit or were unwilling to undergo radical surgery. Patients who were preoperatively staged as T1 tumor but were found to be pathologically T2 also were included. RESULTS: Overall, we performed 59 transanal endoscopic microsurgery operations for rectal cancers, of which 21 were for T2 cancers. In 16 (76 percent) of the T2 patients, the tumors were completely removed with clear margins by transanal endoscopic microsurgery and no additional surgery was performed, except for 2 ...
The management of penetrating abdominal stab wounds has been the subject of continued reappraisal... more The management of penetrating abdominal stab wounds has been the subject of continued reappraisal and controversy. In the present study a novel method which combines the use of diagnostic laparoscopy and DPL, termed laparoscopic diagnostic peritoneal lavage (L-DPL) is described Five trauma patients with penetrating injuries to the lower chest or abdomen were included. Standard videoscopic equipment is utilized for the laparoscopic trauma evaluation of the injured patient. When no significant injury is detected, the videoscope is withdrawn and 1000 mL of normal saline is infused through the abdominal trochar into the peritoneal cavity, and the effluent fluid studied for RBCs, WBC, amylase debry, bile as it is uced in regular diagnostic peritoneal lavage Laparoscopic peritoneal lavage (L-DPL) was then performed and proved to be negative in all 5 patients. RBC lavage counts above 100,000/mcrl were not considered as a positive lavage result, because the bleeding source was directly obse...
Bleeding from the small intestine is still a very difficult diagnostic problem, even with the mos... more Bleeding from the small intestine is still a very difficult diagnostic problem, even with the most advanced diagnostic procedures. This report suggests the use of intraoperative endoscopy of the small intestine by the introduction of a colonoscope through the mouth. The whole length of the small intestine can be invaginated on the advancing colonoscope and even intramural lesions can be
Distal margin &amp;amp;amp;amp;amp;amp;gt;1 cm provides an oncologic safety in low-lying rect... more Distal margin &amp;amp;amp;amp;amp;amp;gt;1 cm provides an oncologic safety in low-lying rectal cancers. We evaluated the accuracy of frozen section (FS) examination in estimating distal margins, and its impact on intraoperative decision making regarding restorative proctectomy. Retrospective study of patients who underwent surgery for adenocarcinoma of the mid or lower rectum during 2001-2010 and for whom a distal margin specimen was examined intraoperatively by FS, to confirm microscopically free margins. Intraoperative findings, and frozen and final paraffin section findings were retrieved from patient charts. A distal margin of ≤1 cm was compared with &amp;amp;amp;amp;amp;amp;gt;1 cm, for free margins at final pathology and local recurrence (LR). The impact of a distal margin ≤5 mm was also assessed. The impact of FS on intraoperative decision making, in patients who did and did not receive preoperative chemoradiotherapy, was assessed. The mean age of the 63 patients studied was 66.4 ± 11.8 years, and median tumor distance from the anal verge 6 cm (range 1-10 cm). Seven patients underwent abdominoperineal resection, 54 anterior resection, and two Hartman procedures. FS sensitivity and specificity were 83% and 98%, respectively. Accuracy of FS was high for the 41 patients treated with preoperative chemoradiotherapy, and the 22 who were not. Distal margin &amp;amp;amp;amp;amp;amp;gt;5 mm at FS examination ensured a free margin at final pathology. LR rate was comparable between patients with distal margin &amp;amp;amp;amp;amp;amp;gt;10 mm and ≤10 mm, 8% vs 11%, P = 0.65. FS examination may help determine free distal margin and consequently, in selected cases, may facilitate a restorative procedure in patients with low rectal cancer.
Rectal duplication cyst is a rare entity that accounts for approximately 4% of all alimentary tra... more Rectal duplication cyst is a rare entity that accounts for approximately 4% of all alimentary tract duplications. To the best of our knowledge, the presented cases are the first reports in the English literature of rectal duplication cyst resection by transanal endoscopic microsurgery. We present two patients; both are 41-year-old women with a palpable rectal mass. Workup revealed a submucosal posterior mass that was then resected by transanal endoscopic microsurgery. The pathology report described cystic lesions with squamous and columnar epithelium and segments of smooth muscle. These findings were compatible with rectal duplication cyst. Our limited experience showed good results with minimal morbidity and mortality for resection of rectal duplication cysts of limited size with no evidence of malignancy.
Transanal endoscopic microsurgery (TEM) was originally designed for local endoscopic excision of ... more Transanal endoscopic microsurgery (TEM) was originally designed for local endoscopic excision of benign and low-grade mucosal rectal lesions through an endoscopic system. The procedure is particularly challenging for submucosal and retrorectal lesions, as the tumor margins are not well defined. To investigate patient and surgical characteristics of TEM as a treatment for submucosal rectal and retrorectal lesions. All the patients in our department of general surgery who underwent TEM for a submucosal rectal or retrorectal lesion, between the years 2001 and 2011, were identified. Their charts were reviewed and data pertaining to demographic characteristics and medical history, including tumor characteristics, were collected. Operative notes and histopathology reports were also reviewed. The adequacy of the tumor resection, that ism attainment of free margins, endoscopic completion of the procedure, and perioperative complications, were assessed. Fifteen patients (5 females, 10 males), mean age 53.9 ± 16.9 years, were identified. The main indications for surgery were gastrointestinal stromal tumor (5 patients) and tailgut or duplication cyst (4 patients). All procedures were completed endoscopically. The median distance from the anal verge was 7.3 cm (range, 5 to 10 cm), and the mean diameter of the tumors was 3 ± 1.1 cm. The one patient in whom the margins presented tumoral involvement underwent repeated TEM. No intraoperative complications were reported. The postoperative complication rate was 13.3%, and the mean length of hospital stay was 1.85 ± 1.77 days. TEM for retrorectal and submucosal rectal lesions is feasible and safe. A remarkably low morbidity rate and limited surgical injury favor TEM in selected patients.
Compared with traditional rectal resection, transanal endoscopic microsurgery (TEM) is faster and... more Compared with traditional rectal resection, transanal endoscopic microsurgery (TEM) is faster and safer. This retrospective study sought to assess the efficacy of TEM for lesions located in the upper rectum, ≥10 cm from the anal verge. Data from all patients who underwent TEM for rectal lesions ≥10 cm from the anal verge between 2001 and 2010 at two medical centers in Israel were retrospectively analyzed. The study group comprised 96 patients (57 men, 39 women) who underwent 99 TEM procedures. Collected data included patient demographics, tumor characteristics, indications for surgery, operative findings and details, postoperative outcomes, and histopathologic findings. Long-term outcomes including local recurrence (LR) for benign lesions and LR and overall survival (OS) for malignant lesions were calculated. Categorical variables were calculated by frequency tables, and linear variables were represented by averages and standard deviation or median with the spread of variables. Survival and LR analysis was performed by Kaplan-Meier and Cox regression methods. The mean tumor distance from the anal verge was 11.3 ± 2 cm and the median tumor size was 2 cm. Early postoperative outcomes were favorable, and no early postoperative mortality was reported. The postoperative morbidity rate was 10%. For long-term outcomes, in the subgroup with benign lesions, after a median follow-up of 8.7 years, the LR rate was 5.1%. In the group with malignant lesions, LR and OS rates were 6.9 and 87%, respectively. TEM for upper rectal lesions is feasible and may be safe in selected cases. Low morbidity rate, shorter operative time and length of stay, no mortality events, and favorable long-term outcomes support the use of TEM for the treatment of lesions in the upper rectum.
We evaluated the role of intraoperative frozen section (FS) in the surgical management of solitar... more We evaluated the role of intraoperative frozen section (FS) in the surgical management of solitary thyroid nodules, as its true value is a subject of some controversy. We reviewed the records of 206 consecutive patients operated on for solitary thyroid nodules. All patients had undergone both preoperative fine-needle aspiration (FNA) and intraoperative FS. The diagnostic findings of FNA cytology and FS histology were compared with the final histological results. There were 61 patients with cancer and 145 with various benign conditions. The sensitivity and specificity of FNA were 78.1% and 96.5%, respectively, demonstrating an overall accuracy of 91.3%. The sensitivity, specificity, and accuracy rates for FS were 83.3%, 95.2%, and 91.7%, respectively. FS altered the operative decision in 14 patients, but correctly so in only 8 patients. Correlated with FNA cytology, the yield of FS in assisting in the intraoperative decision making was 1.8%, 3.4%, and 5.2% for benign, malignant, and suspicious cytology, respectively. When the results of FNA and FS are interpreted as either benign or malignant, both are highly accurate predictors of the pathological nature of the nodule. However, the findings of the present study do not support the use of FS in the surgical management of solitary thyroid nodules, regardless of FNA cytology.
Retrorectal tumors are an uncommon pathological entity. Their clinical importance arises from the... more Retrorectal tumors are an uncommon pathological entity. Their clinical importance arises from their occasional malignant nature or malignant transformation. The treatment of choice for most presacral tumors is surgical excision. The approach depends upon the upper limit of the lesion and the presumptive pathology. We reviewed the main features of these tumors with emphasis on transanal endoscopic microsurgery (TEM) as a viable surgical approach for the treatment of the lesions, undertaken in our institution. We present our small case series, consisting of six patients with retrorectal lesions who underwent local excision via TEM. Early and late postoperative outcomes are presented. TEM for retrorectal lesions appears to be a feasible and safe approach. A remarkably low morbidity favors TEM in selected patients.
Intussusception is the most common cause of bowel obstruction in children, but it is a very rare ... more Intussusception is the most common cause of bowel obstruction in children, but it is a very rare cause of bowel obstruction in the elderly. Diagnosis is based on a high index of suspicion, complete anamnestic recall, physical examination, and imaging modalities. We find abdominal CT scans to be highly sensitive and accurate for making the diagnosis.
Journal of Laparoendoscopic & Advanced Surgical Techniques, 2013
The benefits of transanal endoscopic microsurgery (TEM) for the excision of benign and low-grade ... more The benefits of transanal endoscopic microsurgery (TEM) for the excision of benign and low-grade malignant lesions in the low and middle rectum are well recognized. This study examined the feasibility and safety of a repeated TEM procedure. Patients who underwent a repeat TEM for excision of rectal lesions, either for involved resection margins or for local recurrence, between the years 2000 and 2010, were identified. Rectal lesion characteristics were retrieved. Mean operative times, length of hospital stay, and intra- and postoperative complications were compared between primary and repeated procedures. The postoperative histopathology reports were reviewed, and the adequacy of resection was determined. All patients completed a questionnaire based on the Wexner score for anal sphincter function evaluation. Fourteen patients (3 female, 11 male) underwent a repeat TEM operation during the study period. All procedures were completed endoscopically. Indications for repeated TEM were involved margins in 12 patients and recurrence of benign tumor in 2. Mean operative time, mean length of hospital stay, and rate of postoperative complications were similar for primary and repeated TEM procedures (62.5 ± 17 versus 55 ± 23 minutes, P=.181; 1.7 ± 1.3 versus 1.7 ± 1.12 days, P=.99; and 35.7% versus 21.4%, P=.66, respectively). The Wexner score was comparable at baseline and after the first and the second TEM procedures (1.5 ± 2.3, 1.5 ± 2.3, and 3.3 ± 3.1, respectively; P=.188). No cases of fecal incontinence following a repeat TEM were documented. Repeated TEM is feasible and safe and may be appropriate for selected patients.
Preoperative stoma site marking and counseling aim to improve patients&amp;amp;amp;amp;amp;am... more Preoperative stoma site marking and counseling aim to improve patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; rehabilitation and adaptation to a new medical condition. Objective studies are needed to provide evidence of the impact of care by stoma therapists. Key quality indicators include patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; quality of life, independence, and complication rates as affected by the variable modes of stoma site marking and planning. The aim of this study was to evaluate the impact of preoperative stoma site marking on patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; quality of life, independence, and complication rates. : A validated stoma quality-of-life questionnaire was used as the main assessment tool. Complications were noted on regular postoperative visits. This is a single-center, clinical study. The study was conducted at the Rambam Health Care Campus in Haifa, Israel. Rambam Health Care Campus is a tertiary university hospital. All patients who underwent an elective stoma creation between 2006 and 2008 were included. Evaluated parameters included demographics, stoma type, marking status, complication rates, quality of life, and independence parameters. : One hundred five patients (60 men and 45 women) were included, of whom 52 (49.5%) were preoperatively marked and 53 (50.5%) were not marked. Sixty stomas (57%) were permanent, and 45 (43%) stomas were temporary. The quality of life of patients whose stoma sites were preoperatively marked was significantly better than that of the unmarked patients (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05 in 18 of 20 items), their independence parameters were significantly better, and their complication rates significantly lower. All of these results were significant irrespective of the stoma type. Preoperative stoma site marking is crucial for improving patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; postoperative quality of life, promoting their independence, and reducing the rates of postoperative complications. The role of the enterostomal therapist is very important in the ostomates&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; pre- and postoperative care.
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