Hanoch Kashtan

Laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure: our algorithm

BACKGROUND Failed sleeve gastrectomy (SG), defined by inadequate weight loss or weight regain, can be treated by a laparoscopic conversion to a biliopancreatic diversion with duodenal switch (DS) or a Roux-en-Y gastric bypass (RYGB). We report the outcomes of these procedures after SG failure. METHODS All patients who underwent DS (n=9) or RYGB (n=10) due to inadequate weight loss or weight regain between December 2006 and November 2012 after a failed SG were enrolled. RESULTS The mean pre-SG weight and body mass index (BMI) for the DS and RYGB patients were 143±36 kg and 51.5±11 kg/m2 and 120±26 kg and 44.5±5 kg/m2, respectively. The interval between the SG and the conversion to DS and to RYGB was 27±18 months and 36±17 months, respectively. The operation time and hospital stay were 191±64 minutes and 4.3±2.4 days for DS, and 111±37 minutes and 3.1±1.1 days for RYGB. At reoperation, the weight, BMI and percentage of excess weight loss (%EWL) were 113±22 kg, 43±6 kg/m2 and 28±16.5% and 107±27.5 kg, 40±5.7 kg/m2 and 25±12.7% (all P>.05), for the DS and RYGB, respectively. None of the patients were lost to follow-up. The post-DS weight, BMI, and %EWL were 84±19 kg, 30.7±7.4 kg/m2, and 80±40%. The post-RYGB weight, BMI, and %EWL were 81±21 kg, 30.2±4.8 kg/m2, and 65.5±34% (all P>.05). CONCLUSION DS and RYGB are feasible and effective operations after a failed SG. The DS yields a greater weight loss. The mechanism of failure should guide selection of the second procedure.

Management of patients with traumatic intracranial injury in hospitals without neurosurgical service.

BACKGROUND Many patients with intracranial bleeding (ICB) are being evaluated in hospitals with no neurosurgical service. Some of the patients may be safely managed in the primary hospital without transferring them to a designated neurosurgical center. In Israel, there are three approaches to alert patients with ICB: mandatory transfer, remote telemedicine neurosurgical consultation, and clinical-radiologic guidelines. We evaluated the outcome of alert patients with low-risk ICB who were managed in centers without neurosurgical service. METHODS A retrospective cohort comparative study. Patients with ICB and a Glasgow Coma Score >12 were included. Low-risk ICB was defined as solitary brain contusion of <1 cm in diameter, limited small subarachnoid hemorrhage, or subdural hematoma of <5 mm in maximal width and length. The decision to transfer the patients to a neurosurgical center was based on one of the three models. Hospital A: mandatory transfer. Hospital B: telemedicine-based consultation with a remote neurosurgeon. Hospital C: clinical-radiologic algorithm-based guidelines. Primary endpoint was the neurologic outcome of patients at discharge. RESULTS There were 152 patients in group A, 98 patients in group B, and 73 patients in group C. All patients of group A were transferred to a neurosurgical center. Fifty-eight percent of patients from hospital B and 26% of patients from hospital C were hospitalized in the primary center despite a proven ICB. These patients were discharged without any neurologic sequel of their injury. Two patients from group B and one patient from group C needed a delayed transfer to a neurosurgical center. None of the patient needed delayed neurosurgical intervention. CONCLUSIONS Despite the small sample size of this study, the presented data suggest that some patients with ICB can be safely and definitively managed in centers with no on-site neurosurgical service. The need for transfer may be based on telemedicine consultation or clinical -radiologic guidelines. Further larger scale studies are warranted.

Photodynamic therapy of colorectal cancer using a new light source : From in vitro studies to a patient treatment

PURPOSE: Photodynamic therapy (PDT) is a relatively new alternative modality for palliation of rectal cancer. Current source of light for PDT are laser systems that are expensive and not necessarily needed for PDT. We evaluated a new nonlaser light source for PDT, Versa-Light®.METHODS AND RESULTS:In vitroPDT—CT26 murine colon carcinoma cells were incubated with aluminum phthalocyanine (AlPcS4) for 48 hours and subjected to photoradiation using Versa-Light®,and viability was assessed. There was a significant decrease in viability of treated cells compared with controls.In vivoPDT—BALB/c mice were injected either subcutaneously or intrarectally with CT26 cancer cells. IP AlPcS4(2.5 mg/kg) was injected when tumors were visible. After 24 hours, mice were subjected to photoradiation. Massive tumor necrosis in response to PDT was observed. PDT also prolonged survival of treated mice. Patient treatment—A 70-year-old woman with recurrent local rectal carcinoma received intravenous Photofrin II®(2 mg/kg). After 48 and 96 hours, she was subjected to direct photoradiation. After the first light session, there was complete macroscopic disappearance of the tumor. Biopsies up to 10 weeks after the treatment showed no cancer cells in the treated area. Sixteen weeks later, a randomized biopsy from previous tumor site showed carcinoma cells. CONCLUSIONS: We believe that Versa-Light®,is a good light source for PDT. It was effective in bothin vitroand animal studies. It can also be safely used for clinical PDT.

Outcome of Right Colectomy for Cancer in Octogenarians

BackgroundColorectal cancer is one of the commonest malignancies in the elderly and, as such, is a major cause of morbidity and mortality. There is no consensus yet if age itself is a risk factor for adverse outcome after colectomy. The aims of the study were to evaluate the impact of age on operative results of right colectomy for cancer and to define factors that influence the postoperative mortality in octogenarians.MethodsData of all patients who underwent right colectomy for colon cancer between January 2001 and December 2006 were collected retrospectively. Patients were divided into two groups: those who were 80 years and older and those who were less than 80 years old. Analysis included patients’ demographics, comorbidities, American Society of Anesthesiologists class, functional status, mode of presentation, stage of disease, length of hospital stay, postoperative morbidity, and mortality.ResultsA total of 124 consecutive patients with right colon cancer were operated. Control group included 84 patients less than 80 year old. Study group included 40 patients 80 years or older. In Cox multivariate regression analysis, poor functional status and emergent surgery were independent factors for postoperative mortality.ConclusionsThere was no significant difference in the outcome of elective right colectomy between elderly patients and their younger counterparts. Operative mortality of emergency surgery was significantly higher in octogenarians. Emergent setting and poor functional status are major risk factors for postoperative mortality.

Photodynamic therapy of cancer of the esophagus using systemic aminolevulinic acid and a non–laser light source: a phase I/II study

Abstract Background: Surgery is the mainstay for the treatment of carcinoma of the esophagus and is also considered to be effective for palliation of dysphagia. Patients who are unfit for surgery represent a difficult therapeutic problem. The goal of the present study was to evaluate the effects of photodynamic therapy by using systemic administration of 5-aminolevulinic acid and a non–laser light source on carcinoma of the esophagus. Methods: Patients were given 60 mg/kg 5-aminolevulinic acid orally. Twenty-four hours later gastroscopy was performed. After initial localization of the tumor with the use of white light, the light source was switched to the red light band at 100 J/cm 2 for 600 seconds. Gastroscopy was repeated at 48 hours and 7 days after the treatment. The degree of dysphagia was recorded before and 14 days after treatment. Results: Five patients with advanced nonresectable tumors or who were unfit for surgery were treated. Two patients had squamous cell carcinoma of the mid-esophagus and three had adenocarcinoma of the distal esophagus. Mild self-limiting photosensitivity was noted in all patients. Liver and renal function tests as well as hemoglobin level and white blood cell count were not affected by the treatment. Improvement of dysphagia was observed in four patients who had pretreatment dysphagia. The patient with the early stage of disease continued to eat a normal diet. Conclusions: Photodynamic therapy with systemic aminolevulinic acid as a photosensitizer and a non–laser light source is feasible and safe in advanced-stage esophageal cancer. It can be an effective modality for the relief of dysphagia in these patients.

Prospective Phase II Study of Neoadjuvant Therapy with Cisplatin, 5-Fluorouracil, and Bevacizumab for Locally Advanced Resectable Esophageal Cancer

Background: We investigated the efficacy and tolerability of cisplatin and 5-fluorouracil (5-FU) plus bevacizumab as neoadjuvant therapy for patients with locally advanced resectable esophageal cancer. Patients and Methods: In this prospective phase II study, 22 patients with adenocarcinoma and 6 with squamous cell carcinoma received 2 4-day cycles of bevacizumab 7.5 mg/kg followed by cisplatin 80 mg/m2 infusion on day 1 followed by 5-FU 1,000 mg/m2 as a 96-h continuous infusion on days 1–4, separated by a 3-week interval. Results: The response rate was 39%, the R0 resection rate was 43%, and the median overall survival (OS) was 17 months. The regimen was well tolerated, with the most common severe toxicities being venous thromboembolism (10%), nausea, and gastrointestinal bleeding (7% each). In 37 patients previously treated with cisplatin and 5-FU alone at our institution and thus serving as historical controls, the response rate was 30%, the R0 resection rate was 44%, and the median OS was 23 months. There was no statistically significant difference between the 2 groups of patients. Conclusion: Adding bevacizumab to cisplatin and 5-FU neoadjuvant chemotherapy was active and well tolerated but did not seem to improve the resection rate or OS compared with prior regimens, including the historical controls at our institution.

Phase II study of UFT with leucovorin plus hepatic arterial infusion with irinotecan, 5-fluorouracil and leucovorin for non-resectable liver metastases of colorectal cancer.

Background: Compared with systemic therapy, hepatic arterial infusion (HAI) increases the response to fluoropyrimidines. Methods: Thirty-one patients with non-resectable, colorectal cancer (CRC) liver metastases received irinotecan 120 mg/m2, followed by leucovorin (LV) 20 mg/m2 and 5-fluorouracil (5-FU) 500 mg/m2 administered by HAI every 2 weeks, plus UFT (tegafur-uracil) 200 mg/m2/day with LV 30 mg/day on days 1–22, followed by a 6-day rest. Results: The objective response rate was 65% (all 20 patients achieving a partial response). Ten patients (32%) had stable disease. The median time to progression (TTP) and overall survival (OS) were 12 and 36 months. OS was similar in patients with low versus high expression of thymidylate synthase (TS) and/or dihydropyrimidine dehydrogenase (DPD). The regimen was well tolerated. Conclusions: UFT with LV plus HAI irinotecan and 5-FU/LV was a feasible and effective treatment for non-resectable CRC liver metastases, increasing response, TTP and OS. TS and DPD levels in liver metastases did not predict outcome.

Effect of photodynamic therapy on normal fibroblasts and colon anastomotic healing in mice.

Photodynamic therapy as an adjuvant modality to surgical resection of colon cancer is feasible provided that it does not affect healing of the anastomosis. The aim of this study was to evaluate the effects of photodynamic therapy on the viability of normal fibroblasts and on the healing process of colonic anastomosis in mice. Both in vitro and in vivo methods were employed. For in vitro study, 2 x 105 human fibroblasts were incubated in triplicate with 5-aminolevulinic acid (2.5 μ g/well) for 48 hours. Cells then underwent photoradiation at light doses of 50,100, and 200 joules/cm2 using a nonlaser light source. Viability was assessed by methylene blue dye exclusion. For in vivo studies, 60 mice were randomized into study and control groups and underwent laparotomy involving colonic anastomosis. The anastomosis underwent photodynamic therapy using 5-aminolevulinic acid (60 mg/kg) as a photosensitizer and a nonlaser light (40 joules/cm2). On postoperative days 1, 4, 7, 14, and 21, six mice were killed and subjected to bursting pressure and histologie examinations. Results of in vitro study showed pretreatment cell viability to be 96% to 99% in both groups. Photodynamic therapy caused no significant change in fibroblast viability at all light doses. Results of in vivo studies showed that the mean bursting pressure of both groups dropped to a low peak on day 4. Subsequently there was a gradual increase in bursting pressure along the examined time points (P <0.001). There was no difference in bursting pressure between the two groups for all time points examined. It was concluded that photodynamic therapy has no effect on viability of normal human fibroblasts and no adverse effects on healing of colonic anastomosis.

Inhibition of CT-26 murine adenocarcinoma growth in the rectum of mice treated with recombinant human interleukin-6

In the present study we evaluated the antitumor effects of recombinant human interleukin-6 (rhIL-6), expressed in Chinese hamster ovary cells, in a murine primary tumor model. We showed that treatment with rhIL-6 substantially inhibited the implantation and growth rates of CT-26 adenocarcinoma tumor cells in the rectal submucosa of syngeneic mice. This effect was achieved by injecting rhIL-6 for 7 consecutive days starting 1 day prior to tumor inoculation. No obvious antitumor effect was noted when rhIL-6 injections started 5 days after tumor inoculation. Analysis of the mechanisms by which rhIL-6 exerts its antitumor effects did not reveal a direct antitumor effect on CT-26 tumor cells or the up-regulation of major histocompatibility complex antigens on these cells. However, infiltration of lymphocytes at the tumor site was observed. Increase of carcinoembryonic antigen by IL-6 was clearly seen in human HT-29 colon carcinoma cells. The possible application of these results for adjuvant immunotherapy of selected colorectal patients and prevention of reimplantation of tumor cells disseminated during surgery is discussed.

Minute-to-minute urine flow rate variability: a new renal physiology variable.

BACKGROUND:Urine output is a surrogate for tissue perfusion and is typically measured at 1-hour intervals. Because small urine volumes are difficult to measure in urine collection bags, considerable over- or underestimation is common. To overcome these shortcomings, digital urine meters were developed. Because these monitors measure urine volume in 1-minute intervals, they provide minute-to-minute measurements of the urine flow rate (UFR). In a previous study, we observed that the minute-to-minute variability in the UFR disappeared during hypovolemia. The aim of this study was to describe the minute-to-minute variability in the UFR as a new physiological variable and to show its relationship to blood volume depletion. METHODS:Seven adult pigs were used in this study. The UFR, minute-to-minute UFR, mean arterial blood pressure, heart rate, and base excess were measured at euvolemia and during gradual hemorrhaging (10%, 20%, and 30% of estimated blood volume). Variance and wavelet spectral analysis were used to measure the disappearance of the minute-to-minute UFR variability. RESULTS:The UFR decreased from 2.2 ± 0.2 to 1.0 ± 0.1 mL/min after a 10% estimated blood volume loss (±1 SE, n = 7, P = 0.0348). The variance in the minute-to-minute UFR decreased from 1.4 ± 0.3 to 0.4 ± 0.1 mL/min (±1 SE, n = 7, P = 0.046). CONCLUSIONS:The UFR and its minute-to-minute variability decrease during hemorrhaging. The variability in the UFR may be useful as an aid for the diagnosis of hypovolemia.