Mahmoud Abu-Gazala

Malignant Appendiceal GIST: Case Report and Review of the Literature

IntroductionGastro-intestinal stromal tumors (GISTs) of the appendix are a rare entity. To date, only a handful has been described in the literature, all of which have been of the benign type.Case ReportWe present the first reported case of a malignant appendiceal GIST. The tumor was discovered when the patient presented with a peri-appendiceal abscess which appeared suspicious on CT. The abscess was drained and managed medically. The patient responded to antibiotic treatment but subsequent CT and biopsy confirmed the diagnosis of appendiceal GIST, and the patient was started on treatment with imatinab mesylate.DiscussionOne week after initiation of therapy, the patient returned with frank peritonitis necessitating surgery. Abdominal exploration revealed an appendiceal GIST locally invading and perforating adjacent bowel. We describe the complex presentation and course of the case as well as a literature review of the appendiceal GISTs and the current approach to treatment.

Robotic-assisted enucleation of a large lower esophageal leiomyoma and review of literature.

Leiomyoma is the most common benign esophageal neoplasm. Different invasive surgical approaches have been described for management of such lesions.

Computerized gradual balloon inflation: a novel strategy of coronary angioplasty superior to a standard manual approach.

BACKGROUND Mechanical trauma caused by PCI is a primary reason for restenosis and subsequent target lesion revascularization (TLR). To minimize this trauma, we developed a computerized angioplasty pressure sensor and inflator device (CAPSID) for gradual inflation. The objective of this prospective randomized study was to examine whether use of CAPSID reduces early and late cardiac events in patients undergoing PCI. METHODS Patients undergoing PCI were eligible and randomized to CAPSID or standard balloon inflation (plain old balloon angioplasty). In the CAPSID group, a slow, gradual balloon inflation was performed by a personal computer. Stenting was used in both groups only for suboptimal results. Patients with total occlusions and vein grafts were excluded. Clinical follow-up for major adverse cardiac events (MACE) was performed at 6 and 12 months, with repeat coronary angiography performed for clinical symptoms or positive stress testing. RESULTS A total of 234 patients completed the study. At 1-year follow-up, the CAPSID group had a significantly lower rate of MACE (21% vs. 37%, P<.005). In patients who underwent angiography, there was a significantly lower rate of restenosis in the CAPSID group (20.2% vs. 35.5%). The reduction in TLR was even more pronounced in the subgroup undergoing stenting (8% vs. 24%; P<.001). CONCLUSIONS We conclude that gradual computerized balloon inflation is more effective than standard manual balloon inflation in reducing adverse coronary events. The combination of CAPSID and subsequent stent deployment was especially effective in reducing TLR.

A novel totally internal laparoscopic liver retractor.

Introduction: Minimally invasive surgery is still in evolution. Throughout the past two decades numerous devices have been developed to enable safer and faster procedures, including anastomosis creating devices, energy sources, and superior imaging. However, retraction capabilities were put aside and currently, organ laparoscopic retraction is based on standard laparoscopic tools. In the era of minimizing the number of ports and shrinking their size, our aim was to develop internal retraction device that could be placed in the peritoneal cavity through a standard trocar, positioned for adequate retraction, and left in place for the entire procedure. These devices would obviate the need for inserting ports dedicated for retraction only and hence contribute to the reduction of the number of incisions. Herein, we present our initial experience with a novel internal liver retractor. Materials and Methods: The Endolift retractor is a simple telescopic rod that has anchoring claws at each end. It can be inserted using 5 mm standard trocar using a dedicated applier and anchored to the peritoneum beside the liver edges thereby lifting the undersurface of the liver and exposing the organs underneath. To achieve retraction of the left lateral segment, the Endolift retractor is anchored lateral to the right diaphragmatic crus on 1 side and lateral to the falciform ligament on the other. Results: A total of 14 operations were performed using the Endolift retractor for liver retraction including antireflux procedure, robotic-assisted Hellers myotomy, bariatric procedures, and bile duct exploration. The left lobe of the liver was adequately retracted and enabled access to the operating field. Repositioning was easily performed with progression of the surgery when necessary. Conclusions: Internal retraction devices such as the Endolift retractor for liver retraction are one step further in minimizing trauma to the abdominal wall during minimal invasive surgery. It obviates the need for extra incisions, frees up the surgeons’ hands, and may enable performing complicated laparo-endoscopic single-site laparoscopy and natural orifice transluminal endoscopic surgery.

Laparoscopic partial nephrectomy using a flexible CO2 laser fiber.

The application of a CO2 laser through a flexible fiber for partial nephrectomy produced good parenchymal incision and hemostasis in an animal model.

An enigma of spontaneous combined transdiaphragmatic, intercostal and abdominal wall hernia

IntroductionCough can be associated with many complications.Materials and methodsWe present a 59-year-old male patient with a very rare combination of a cough-related stress fracture of the ninth rib and herniation through the diaphragm and abdominal wall to the subcutaneous tissue of the chest wall. We suggest thoracotomy through the affected intercostal defect as a surgical approach. The diaphragm, chest wall and abdominal tears were repaired separately, and the abdominal wall was reinforced with mesh. Technical aspects were discussed.ConclusionsThough each individual injury is well documented in the literature, this is a rare combination of defects, requiring early recognition to provide repair before incarceration and further enlargement of the defects occur.

Combating terror: A new paradigm in student trauma education

BACKGROUND Other than the Advanced Trauma Life Support course, usually run for postgraduate trainees, there are few trauma courses available for medical students. It has been shown that trauma teaching for medical students is sadly lacking within the undergraduate curriculum. We stated that students following formal teaching, even just theory and some practice in basic skills significantly improved their management of trauma patients. METHODS Hadassah-Hebrew University in Israel runs an annual 2-week trauma course for final-year medical students. The focus is on hands-on practice in resuscitation, diagnosis, procedures, and decision making. After engaging a combination of instructional and interactive teaching methods including practice on simulated injuries that students must assess and treat through the 2 weeks, the course culminates in a disaster drill where students work alongside the emergency services to rescue, assess, treat, and transfer patients. The course is evaluated with a written precourse and postcourse test, an Objective Structured Clinical Examination and detailed feedback from the drill. RESULTS We analyzed student feedback at the end of each course during a 6-year period from 2007 to 2012. Correct answers for the posttest results were higher each year with good reliability as assessed by Chronbach’s &agr; and with significant variation from pretest scores assessed using paired-samples t tests. Best scores were achieved in knowledge acquisition and practical skills gained. Students were also asked whether the course contributed to self-preparedness in treating trauma patients, and this consistently achieved high scores. CONCLUSION We believe that students benefit substantially from the course and gain lasting skills and confidence in trauma management, decision making, and organizational skills. The course provides students with the opportunity to learn and ingrain trauma principles along Advanced Trauma Life Support guidelines and prepares them for practice as safe doctors. We advocate the global implementation of a student trauma training course as a mandatory educational initiative and propose our course format as a model for similar courses.

Comparing laparoscopic mesh fixation strength between articulated and non-articulated tack devices

Abstract Aim: The iMESH Tacker™ (IMT) device is a device which simplifies laproscopic hernia repair by enabling an articulation of the device tip. The study compares the strength of mesh fixation between the IMT and another commercial tack (ACT) device – Absorbatack™ (Covidien, Corp, Mansfield, MA, USA). Material and methods: Strips of mesh were installed on the abodminal wall of three pigs. Half of the meshes were fixated by IMT and half by ACT. Euthanasia was done immediately to the first pig, after14 days to the second and after 27 days to the third pig. The mesh strips were pulled while fixation force was measured. Statistical analysis was done using the two tailed t-test. All mesh strips were found to be fixated. Through detachment force test, the average force in the first pig was 17.1N ± 1.9 and 16.5N ± 8.3 (IMT and ACT respectively, n/s). The average force in the second pig was 18.8N ± 7.3 and 8.4N ± 4.1 (IMT and ACT respectively, p < 0.05). The average force in the third pig was 16.3N ± 5.3 and 10.9N ± 5.9 (IMT and ACT respectively, p < 0.05). Conclusion: The use of IMT is both feasible and easy to learn. The study showed that IMT creates average fixation force which is higher than ACT.

Early outcome after laparoscopic sleeve gastrectomy of type two diabetes mellitus patients with extremely elevated glycated hemoglobin (HbA1c)

BACKGROUND Due to high prevalence of type 2 diabetes mellitus (T2DM) and increasing popularity of bariatric and metabolic operations, Surgeons are faced with patients with relatively more severe T2DM disease. High level of glycated hemoglobin (HbA1c) is widely considered as a marker for uncontrolled T2DM. The aim of this study was to explore the correlation between high level of pre-operative HbA1c, peri-operative morbidity and post operative outcome after laparoscopic sleeve gastrectomy. METHODS We conducted a retrospective study based on our medical center metabolic and bariatric registry. The inclusion criteria for selecting patients to the study group was HbA1c of 9 gram/dL and higher. A comparison control study was designed to include T2DM patients similar in all characteristics except for HbA1c of 7.5 gram/dl and less. RESULTS We included 20 patients who underwent laparoscopic sleeve gastrectomy. Each group of patients included half of the patients. The mean pre operative HbA1c in the studied and the control group were 10.4 gram/dL and 7.1 gram/dL respectively (p<0.001). There were no differences in peri-operative morbidity and length of stay at the hospital. Mean excess weight loss, fasting glucose levels and HbA1c levels were similar six months post surgery mean. CONCLUSIONS According to our study we have not found correlation between high HbA1c levels and increased peri-operative morbidity or insufficient excess weight loss among patients who underwent laparoscopic sleeve gastrectomy.

Revascularization of the celiac and superior mesenteric arteries after operative injury using both splenic artery and saphenous graft.

We report a case of iatrogenic resection of both the superior mesenteric artery (SMA) and celiac artery during left nephrectomy and adrenalectomy. A 47-year-old woman was diagnosed with a large adrenal tumor and underwent a laparoscopic left adrenalectomy that was converted to open adrenalectomy and nephrectomy as a result of a bulky tumor. Both the SMA and celiac artery were inadvertently cut at their origin because of adherence of the tumor to the aorta. Both arteries were revascularized by anastomosing the distal splenic artery to the aorta after performing splenectomy to revascularize the celiac circulation and using an autologous saphenous vein graft to revascularize the SMA. The patient had no postoperative complications. To our knowledge, this is the first description of use of the splenic artery for celiac revascularization.