Shmuel Avital

Evaluation of peritoneal CEA levels following colorectal cancer surgery

Peritoneal carcinoembryonic antigen (pCEA) levels in the early postoperative period following a curative resection of colorectal cancer (CRC) have not been previously studied.

Laparoscopic-assisted extralevator abdominoperineal excision using a parastomal prophylactic mesh and a biological mesh for pelvic floor reconstruction.

Extralevator abdominoperineal resection (ELAPR) for low rectal cancers has shown superior oncological results compared with conventional abdominoperineal resection (APR) with less circumferential margin (CRM) involvement, less intraoperative bowel perforation and a lower local recurrence rate [1]. There is currently no standardized technique for ELAPR. Different related aspects such as the use of laparoscopy, the extent of pelvic dissection, the method of pelvic floor reconstruction or the application of a parastomal prophylactic mesh may be considered. Laparoscopic dissection may consist of limited pelvic dissection [2] or more extensive dissection including laparoscopic transabdominal levator transection [3]. Closure of the large perineal defect is challenging and may be approached by several methods [4], and the high risk of a future parastomal hernia may justify the use of a prophylactic parastomal mesh [5]. We present here our laparoscopic-assisted ELAPR approach. Our final technique includes a laparoscopic pelvic dissection and creation of a stoma reinforced by a prophylactic mesh, and a perineal phase consists of en bloc removal of the rectum with the levators followed by reconstruction of the pelvic floor with a biological mesh. Operative technique

Surgery for Rectal Cancer

The rectum is approximately 18 cm in length and is divided into the upper intraperitoneal third and the lower extraperitoneal two-thirds. The surgical approach and clinical outcome of upper rectal tumors are similar to cancer of the colon. As opposed to colon and upper rectal cancer, surgery for locally advanced low and mid rectal cancer has been associated with high local recurrence rates, reportedly as high as 30% until the late 1990s. Two factors that have contributed to a substantial decrease in the local recurrence rate following surgery for locally advanced rectal cancer are completion therapy with radiation, and the adoption of a surgical technique – total mesorectal excision radiation – used to be administered after the operation (termed adjuvant radiotherapy) but is now generally given prior to surgery (called neoadjuvant radiotherapy).

Laparoscopic Rectal Resection

Several large, prospective, randomized studies have demonstrated benefits from the use of laparoscopic surgery for colon cancer compared to open laparotomy. Laparoscopic colon cancer surgery is associated with a shorter and easier postoperative recovery. These advantages have also been shown for rectosigmoid cancers including upper rectal tumors (12–18 cm from the anal verge). However, there are very few prospective randomized trials evaluating the oncologic safety and benefits of laparoscopic resection for cancer in the lower two-thirds of the rectum.

Surgery for Hidradenitis Suppurativa

Acute infection in the setting of hidradenitis will manifest as subcutaneous abscesses. Very small abscess that does not cause significant pain may be managed with antibiotics and local measures. Most abscesses will cause pain, drainage, and a foul odor, and require surgical drainage. When a region of hidradenitis can no longer be managed with drainage and debridement, or the patient desires definitive management, then full-thickness excision of the affected skin should be performed. In addition, very long standing disease (20–30 years) presents a low, but not insignificant, risk of squamous cell carcinoma.

Different approaches for Endo-SPONGE® insertion to treat rectal anastomotic leaks

Rectal anastomotic leaks may present in different degrees of severity. Significant leaks are life-threatening events and may lead to a permanent stoma [1]. The treatment goal in such cases is sepsis control and an attempt to preserve the rectal anastomosis. Vacuum-assisted closure (VAC) devices have been shown to accelerate wound healing by increasing local blood flow, reducing bacterial load, and stimulating growth of granulation tissue [2]. The Endo-SPONGE® system (B. Braun, Melsungen, Hessen, Germany) was designed on the same principles to specifically treat rectal anastomotic leaks and was first introduced in 2008 [3]. This vacuum-assisted device consists of a sponge inserted endoscopically through the dehiscence site into the paraanastomotic space and connected to a small container which exerts a constant suction at 120 psi. Preliminary promising results in the treatment of paraanastomotic abscesses following anastomotic leakage lead to a wider use of this device with favorable outcomes [4, 5]. The traditional method for the insertion of the EndoSPONGE® based on its original design is by endoscopy [3]. We have recently used Endo-SPONGE® in six patients. However, we used a different approach to insert it, based on the height of the anastomosis. In cases of leakage from a low rectal anastomosis, it was inserted digitally, and in cases of high anastomotic leaks, we used transanal minimally invasive surgery (TAMIS) approach. We describe in here our initial results and long-term patient outcome. Materials and methods

The effect of bariatric surgery on hypothyroidism: Sleeve gastrectomy versus gastric bypass

BACKGROUND Hypothyroidism is prevalent in morbidly obese patients and may improve after a weight reduction surgery. OBJECTIVES Laboratory and clinical changes in hypothyroid patients undergoing laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) were compared and evaluated. SETTINGS Data were retrieved from a prospectively collected database of 2 public bariatric units. METHODS Patients with hypothyroidism prior to bariatric procedure were evaluated for changes in thyroid stimulating hormone (TSH) and changes or cessation of hormone replacement therapy after surgery. Correlation between changes in TSH levels and percentage of excess weight loss and comparison between effects of LSG and LRYGB were evaluated. RESULTS Ninety patients were included. Mean follow-up was 11 ± 9 .73 months. Mean body mass index decreased from 43.8 to 33.2 kg/m2. Forty patients had deranged elevated TSH levels prior to surgery that decreased significantly after surgery (mean 6.6 ± 1.9 to 2.9 ± 1.5 mU/L, P < .01). Of patients receiving hormone replacement therapy prior to surgery, 42% required lower doses, with a 61% mean decrease in doses, while 10% stopped hormone replacement therapy completely. No correlation was found between the improvement in TSH and percentage of excess weight loss. A significant advantage to one of the bariatric procedures (LSG [61] and LRYGB [29]) could not be established. CONCLUSIONS LSG and LRYGB both proved to improve thyroid function in hypothyroid obese patients. No procedure was found to be superior. No correlation was found between percentage of excess weight loss and TSH reduction. This implies that the effect of bariatric surgery on the improvement of thyroid functions is mediated by mechanisms other than weight loss, probably hormonal.

Ileo-ileal intussusception of a sutured enterotomy site, 6 days after laparotomy due to fetobezoar: A case report

Highlights • A case report of postoperative ileo-ileal intussusception with a sutured enterotomy site as a lead point is described.• This is a rare postoperative complication in the adult.• A review of the relevant literature is presented.

Surgical Management of Radiation-Induced Intestinal Injury

Radiation therapy has been utilized as an important component in the treatment of pelvic malignancy for many decades. Its toxic effect on the small and large intestines may lead to complications that necessitate surgical intervention, such as obstruction, perforation, fistulization, and intractable bleeding. Due to the nature of the damage caused by radiation to the bowel, surgical treatment poses a significant challenge for the operating surgeon, and requires special considerations. This chapter will outline the principles and practice of current surgical management for patients with radiation injury of the intestinal tract.

Surgery for Anal Fissure

Treatment of an anal fissure, either medical or surgical, is aimed at relaxation of the hypertonic internal sphincter. Breaking the cycle of spasm of the sphincter will allow for healing of the fissure. Alternatively, patients desiring more immediate relief of symptoms are potential surgical candidates. Lateral internal sphincterotomy is the primary surgical procedure used to treat anal fissure. Candidates include patients who have failed a course of medical and/or botulinum toxin injections.