Yehuda Hershkovitz

Computed tomography is not justified in every pediatric blunt trauma patient with a suspicious mechanism of injury.

OBJECTIVE Computed tomography (CT) has become an important tool for the diagnosis of intra-abdominal and chest injuries in patients with blunt trauma. The role of CT in conscious asymptomatic patients with a suspicious mechanism of injury remains controversial. This controversy intensifies in the management of pediatric blunt trauma patients, who are much more susceptible to radiation exposure. The objective of this study was to evaluate the role of abdominal and chest CT imaging in asymptomatic pediatric patients with a suspicious mechanism of injury. METHODS Forty-two pediatric patients up to 15 years old were prospectively enrolled. All patients presented with a suspicious mechanism of blunt trauma and multisystem injury. They were neurologically intact and had no signs of injury to the abdomen or chest. Patients underwent CT imaging of the chest and abdomen as part of the initial evaluation. RESULTS Thirty-one patients (74%) had a normal CT scan. Two patients of 11 with an abnormal CT scan required a change in management and were referred for observation in the Intensive Care Unit. None of the patients required surgical intervention. CONCLUSION The routine use of CT in asymptomatic pediatric patients with a suspicious mechanism of blunt trauma injury is not justified.

A comparative study on two different pathological methods to retrieve lymph nodes following gastrectomy

BACKGROUND The number of lymph nodes harvested during gastrectomy depends on the extension of lymphadenectomy and the method of lymph node retrieval. AIM The objective of this study was to evaluate two methods of lymph node retrieval in specimens of gastric cancer. METHODS The number of lymph nodes was compared using two different techniques. The technique used in the first group was manual dissection following formalin fixation, and the techniques used in the second group was fat-clearing by acetone. RESULTS Both groups were comparable for demographic and pathological variables. The average number of harvested nodes was 19.3 ± 10 for the manual group as compared to 26.1 ± 14 in the acetone group (P = 0.003). The differences in the average number of positive nodes did not reach statistical significance (4.6 compared to 6.9 nodes). CONCLUSION The acetone clearing technique enables the evaluation of a larger number of nodes. An increase, but statistically non significant, number of positive nodes was noted in the acetone group.

The Effect of Afternoon Operative Sessions of Laparoscopic Cholecystectomy Performed by Senior Surgeons on the General Surgery Residency Program: A Comparative Study

OBJECTIVE Laparoscopic cholecystectomy (LC) has been the gold standard for surgical treatment of gallbladder disease since 1980. This laparoscopic surgical procedure is one of the first to be performed by general surgery residents. There is a learning curve required to excel at performing LC. During this period, the operation needs to be performed under the supervision of a senior surgeon. The purpose of this study was to compare LC performed by residents with that performed by senior surgeons using the following parameters: operative time, conversion rate, complication rate, and mean length of hospital stay. METHODS This retrospective study included 1219 patients who underwent elective LC in our institute-788 operated on by a senior surgeon and 431 by a resident. RESULTS The mean operative time was 39 ± 19 minutes. There was a significant difference between the groups, as the mean operative time for the resident group was 49.9 ± 13 compared with 33.7 ± 6 for the senior surgeon group. The overall conversion rate was 2.1%, the complication rate was 2.2%, and the mean length of hospital stay was 1.5 days. There were no statistically significant differences between the groups for these parameters. CONCLUSIONS The only significant difference between the groups was a longer operative time, as the conversion rate, complication rate, and mean length of stay were the same. Therefore, it is safe for LC to be performed by residents supervised by a senior surgeon.

Tumor differentiation as related to sentinel lymph node status in gastric cancer

AIM To investigate the influence of tumor grade on sentinel lymph node (SLN) status in patients with gastric cancer (GC). METHODS We retrospectively studied 71 patients with GC who underwent SLN mapping during gastric surgery to evaluate the relationship between SLN status and tumor grade. RESULTS Poorly differentiated tumors were detected in 50/71 patients, while the other 21 patients had moderately differentiated tumors. SLNs were identified in 58/71 patients (82%). In 41 of the 58 patients that were found to have stained nodes (70.7%), the tumor was of the poorly differentiated type (group I), while in the remaining patients with stained nodes 17/58 (29.3%), the tumor was of the moderately differentiated type (group II). Positive SLNs were found in 22/41 patients in group I (53.7%) and in 7/17 patients in group II (41.2%) (P = 0.325). The rate of positivity for the SLNs in the two groups (53.7% vs 41.2%) was not statistically significant (P = 0.514). CONCLUSION Most of our patients were found to have poorly differentiated adenocarcinoma of the stomach and there was no correlation between tumor grade and SLN involvement.

Influence of colectomy type and resected specimen length on number of harvested lymph nodes

BACKGROUND The optimal (minimal) number of harvested nodes is still a matter of debate. We prospectivly evaluated the relation between specimen length and tumor location to the number of harvested nodes and rate of node positivity. METHODS Specimens of right hemicolectomy, left hemicolectomy, and subtotal colectomy were assessed for specimen length, overall number of harvested lymph nodes, and lymph node ratio. RESULTS Left hemicolectomies were performed in 106 patients, right hemicolectomies in 90, and subtotal colectomies in 9. The mean number of retrieved lymph nodes was significantly higher in patients with right and subtotal colectomies compared to left colectomies: 33, 44, and 24, respectively. Positive nodes were found in 34% of the patients with right hemicolectomies, 55% in the subtotal group, and 35% in the left hemicolectomy group (not statistically significant). The length of the resected specimen was significantly longer in patients with right and subtotal colectomies compared to left colectomy: 31, 83, and 19 cm, respectively, but the ratio of lymph nodes to the length of the specimen was not statistically different: 1.19, 0.58, and 1.55, respectively. CONCLUSIONS It appears that the additional length of resection in right colectomies compared to left colectomies leads to an increase in the average number of resected nodes, a change that did not translate into an increase in the number of positive nodes, nor in the ratio of patients with positive nodes.

Frequency of intra-abdominal organ injury is higher in patients with concomitant stab wounds to other anatomical areas

BackgroundManagement of stable patients with abdominal stab wound remains controversial, particularly for those with no clear indications for explorative laparotomy. We evaluated the risk of intra-abdominal injury in stab wound victims concomitantly stabbed in other anatomical body areas.MethodsWe performed a retrospective cohort study of patients with abdominal stab wounds recorded in the Israeli National Trauma Registry from January 1st, 1997, to December 31st, 2013. Patients with an isolated abdominal stab wound were compared to those with concomitant stab wounds to other anatomical areas. Intra-abdominal organ injury was defined by imaging or surgery findings. Multivariate analysis using a logistic regression model was conducted to assess independent risk for intra-abdominal organ injury.ResultsThe study included 3964 patients. After controlling for age, gender and hypotension on arrival, patients with multi-regional stab wounds had an increased risk of intra-abdominal injury (OR = 1.3, CI 95% 1.1–1.6, p < 0.001). These patients also had a higher rate of injury to the solid organs than patients with an isolated abdominal stab wound.ConclusionsPatients with multi-regional stab wounds have an increased risk of intra-abdominal injury. Worldwide accepted “clinical follow up” protocol may not be appropriate in management of patients with multi-regional stab wounds.