Zvi Kaufman

Fecal fistula: A late complication of Marlex® mesh repair

Marlex® mesh is an excellent prosthetic material for closure of major abdominal defects. Most of its complications are seroma and infections. We have used Marlex mesh intraperitoneally for closure of burst abdomen in a patient who had a gastrectomy for recurrent duodenal ulcer. A year and a half later, this patient developed a fecal fistula to the skin due to incorporation of the Marlex mesh into the splenic flexure of the colon. The patient underwent a second operation during which the fistula was resected and the Marlex removed. We concluded that intraperitoneal placement of Marlex mesh is not recommended.

A prospective, randomized, controlled, multicenter study of a real-time, intraoperative probe for positive margin detection in breast-conserving surgery

BACKGROUND This randomized, double-arm trial was designed to study the benefit of a novel device (MarginProbe, Dune Medical Devices, Caesarea, Israel) in intraoperative margin assessment for breast-conserving surgery (BCS) and the associated reduction in reoperations. METHODS In the device group, the probe was applied to the lumpectomy specimen and additional tissue was excised according to device readings. Study arms were compared by reoperation rates and by correct surgical reaction confirmed by histology. RESULTS Three hundred patients were enrolled. Device use was associated with improved correct surgical reaction, defined as additional re-excision in all histologically detected positive margins, with tumor within 1 mm of inked margin. The repeat lumpectomy rate was significantly reduced by 56% in the device arm: 5.6% versus 12.7% in the control arm. There were no differences in excised tissue volume or cosmetic outcome. CONCLUSIONS Intraoperative use of the MarginProbe for positive margin detection is safe and effective in BCS and decreases the rate of repeat operations.

Aberrant crypt foci in human colons: distribution and histomorphologic characteristics.

Aberrant crypt foci (ACF) are one of the earliest putative preneoplastic, and in some cases, neoplastic lesions in human colons. These microscopic lesions, identified on methylene blue-stained mucosa with a low-power-magnification microscope, are thought to be closely related to the earliest steps in multistage colonic tumorigenesis. We investigated the distribution pattern and histomorphological features of ACF in 74 patients with sporadic colorectal cancer. The distribution pattern shows a slightly higher prevalence with older age. The prevalence of the ACF in sigmoid colon was significantly higher in patients with colorectal cancer as compared with patients with benign colonic diseases. Also, significantly more ACF were detected in distal parts of the large bowel (descending, sigmoid colon, and rectum) than in proximal parts. Of 42 microdissected lesions, 12 were dysplastic and 30 were hyperplastic foci. The average size of dysplastic lesions was significantly larger than hyperplastic foci. More apoptotic bodies were found in dysplastic lesions. These lesions also showed an upward expansion of proliferative compartment and higher proliferation indices expressed as proliferating cell nuclear antigen-labeling index. Lymphoid follicles were frequently observed in the base of both hyperplastic and dysplastic foci (40% and 66.6%, respectively). The coincidence of lymphoid follicles was 2.5 to 8 times higher than expected. These features may be related to further progression of selected ACF during colorectal tumorigenesis.

Proliferating cell nuclear antigen as a marker of cell kinetics in aberrant crypt foci, hyperplastic polyps, adenomas, and adenocarcinomas of the human colon*

BACKGROUND One of the first steps in multistage colonic carcinogenesis is increased cell proliferation and an upward shift of the proliferation zone of colonic crypts. In the present study, progression in cell kinetics was followed up at all sequential stages of colonic carcinogenesis, starting with aberrant crypt foci (ACF), the earliest putative preneoplastic lesions, hyperplastic and dysplastic polyps, and invasive carcinomas. MATERIALS AND METHODS Colonic tissue and tumor specimens were prospectively obtained from 65 patients treated at our hospital for adenocarcinoma or malignant polyps. For identification of ACFs, dissected mucosal strips obtained from patients with colorectal cancer were stained with 0.1% methylene blue and scanned under dissecting microscope. Paraffin-embedded ACFs and macroscopic lesions were serially sectioned, deparaffinized, and stained with a monoclonal antiproliferating cell nuclear antigen (PCNA) antibody. The PCNA-labelling index (PCNA-LI), expressed as a ratio of positively stained nuclei to total nuclei counted, was calculated separately for basal, middle, and upper colonic crypt compartments. A comparison of the PCNA-LI was made for each compartment in normal mucosa, and hyperplastic and dysplastic lesions. RESULTS A stepwise increase in the PCNA-LI was observed during neoplastic progression of colonic lesions. The two most important variables of increased cell proliferation, expressed as PCNA-LI per crypt compartment, were the presence of dysplasia and the size of dysplastic lesions. CONCLUSIONS In colorectal carcinogenesis, hyperproliferation with upward expansion of proliferative compartment is a characteristic feature at all stages of malignant progression.

Frozen-section diagnosis in surgical pathology: a prospective analysis of 526 Frozen sections

Five hundred eighty‐six consecutive frozen‐section consultations performed during a 1‐year period were studied prospectively in order to assess the accuracy of the method and develop a quality control mechanism. The overall accuracy was 97.1%. The accuracy of the method with breast lesions was 97.9%. Specimens from the gastrointestinal tract and thyroid were incorrectly interpreted in 5% of the cases. The accuracy for lymph node specimens was 96.2%, with more than 50% consulted out of curiosity. The authors conclude that frozen section of lymph node is not recommended. Most of the errors were sampling errors made by the pathologist. The authors therefore conclude that in clinically suspected malignancy, more than one sample must be examined in order to decrease the false‐negative diagnosis in frozen section.

Single dose prophylaxis in elective cholecystectomy: A prospective, double-blind randomized study

We tested the effectiveness of a single dose of prophylactic antibiotic (gentamicin) in elective cholecystectomy in a double-blind, controlled randomized study. All patients recognized preoperatively as being at risk were excluded. The treatment group comprised of 102 patients received a single dose of gentamicin and the 74 patients in the control group received a placebo. Of the patients who received gentamicin, wound infection developed in 4.9 percent versus 13.5 percent in the control group. Among 45 patients who had positive bile cultures, the wound infection rate for those in the treatment group was 14 percent versus 44 percent for those in the control group. Of 17 patients who underwent unexpected exploration of the choledochus, none of those in the treatment group had development of wound infection. The rate of wound infection in the control group was 50 percent. As 30 percent of the patients undergoing elective cholecystectomy were found to have risk factors for the development of wound infection which could not be identified preoperatively, we recommend single dose prophylaxis for all patients undergoing cholecystectomy.

Definitive management of acute pilonidal abscess by loop diathermy excision

A simple technique of definitive management of acute pilonidal abscess is described. The procedure consists of incision with drainage of pus followed by controlled excision of diseased tissue and lateral sinuses, using a loop diathermy. It allows one-stage definitive management of both acute pilonidal abscess and chronic pilonidal sinuses.

Avoiding colostomy soiling during immediate maturation after Hartmann's procedure

A simple maneuver that avoids soiling of the field during immediate maturation of colostomy performed for large bowel obstruction is presented. This maneuver involves inflating a large Foley catheter in the lumen of the obstructed large bowel just before maturation is performed.