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Parnasa SY, Mizrahi I, Helou B, Cohen A, Abu Gazala M, Pikarsky AJ, Shussman N. Incidence and Risk Factors for Low Anterior Resection Syndrome following Trans-Anal Total Mesorectal Excision. J Clin Med 2024; 13:437. [PMID: 38256571 PMCID: PMC10816902 DOI: 10.3390/jcm13020437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/31/2023] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Trans-anal total mesorectal excision (Ta-TME) is a novel approach for the resection of rectal cancer. Low anterior resection syndrome (LARS) is a frequent functional disorder that might follow restorative proctectomy. Data regarding bowel function after Ta-TME are scarce. The aim of this study was to evaluate the incidence and risk factors for the development of LARS following Ta-TME. METHODS A prospectively maintained database of all patients who underwent Ta-TME for rectal cancer at our institution was reviewed. All patients who were operated on from January 2018 to December 2021 were evaluated. The LARS score questionnaire was used via telephone interviews. Incidence, severity and risk factors for LARS were evaluated. RESULTS Eighty-five patients underwent Ta-TME for rectal cancer between January 2018 and December 2021. Thirty-five patients were excluded due to ostomy status, death, local disease recurrence, ileal pouch or lack of compliance. Fifty patients were included in the analysis. LARS was diagnosed in 76% of patients. Anastomosis distance from dentate line was identified as a risk factor for LARS via multivariate analysis (p = 0.042). Neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS. CONCLUSION LARS is a frequent condition following ta-TME, as it is used for other approaches to low anterior resection. Anastomosis distance from dentate line is an independent risk factor for LARS. In this study neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS. Further studies with longer follow-up times are required to better understand the functional outcomes following Ta-TME.
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Affiliation(s)
| | | | | | | | | | | | - Noam Shussman
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (S.Y.P.)
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Abu Gazala M, Brodie R, Yuval JB, Kornblau G, Neustadter D, Mintz Y. Sutureless energy-based wound closure: a step in the quest for trocar site hernia prevention. MINIM INVASIV THER 2021; 31:567-572. [PMID: 33459096 DOI: 10.1080/13645706.2021.1871630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Easy and safe methods of fascia closure are needed in order to reduce the risk for trocar site hernias without affecting procedure time significantly. Here we present a method for port site closure using heat induced collagen denaturation. MATERIAL AND METHODS Controlled heat-induced collagen denaturation was applied to laparoscopic trocar sites in living porcine animal models. These were compared to control trocar sites which were left open. Port sites were evaluated visually at days 14 and 28 after the procedure, and both visually and pathologically at post-procedural day 42. RESULTS A total of 12 port sites were evaluated in three pigs. No incisional hernias were noted at any of the trocar sites in both groups. Histological evaluation revealed that one of the six control ports appeared to have a complete transfascial defect, whereas none of the study group trocars showed this finding. Furthermore, the study port sites showed a more robust scarring pattern. CONCLUSIONS Heat-induced collagen denaturation in this preliminary study was found to be safe and allowed better scarring of the healing port sites. We believe that this technology may offer a safe and efficient closure of laparoscopic trocar sites. More studies are needed to further evaluate the true effectiveness of this technology.Abbreviations: TSH: trocar site hernia; IACUC: institutional animal care and use committee.
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Affiliation(s)
- Mahmoud Abu Gazala
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Ronit Brodie
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jonathan B Yuval
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | | | - Yoav Mintz
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Israel
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Abstract
Rectovaginal fistulas are a relatively rare, but debilitating condition which pose a significant treatment challenge. Areas covered: In this manuscript we discuss the etiology, classification as well as the manifestations and evaluation of rectovaginal fistulas. We summarize the different surgical techniques and evaluate their success rates and perioperative considerations according to cited sources. Expert commentary: A deep understanding of the disease, treatment options, and familiarity with the different surgical treatment options available is mandatory for choosing the correct treatment. When the surgical treatment is tailored to the specific fistula and patient, many patients can eventually have successful resolution. This review will address the management and patient outcomes after treatment for rectovaginal fistulas.
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Affiliation(s)
- Mahmoud Abu Gazala
- a Department of Colorectal Surgery , Cleveland Clinic Florida , Weston , FL , USA
| | - Steven D Wexner
- a Department of Colorectal Surgery , Cleveland Clinic Florida , Weston , FL , USA
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Abstract
Throughout history, surgeons have been on a quest to refine the surgical treatment options for their patients and to minimize operative trauma. During the last three decades, there have been tremendous advances in the field of minimally invasive colorectal surgery, with an explosion of different technologies and approaches offered to treat well-known diseases. Laparoscopic surgery has been shown to be equal or superior to open surgery. The boundaries of laparoscopy have been pushed further, in the form of single-incision laparoscopy, natural-orifice transluminal endoscopic surgery and robotics. This paper critically reviews the pathway of development of minimally invasive surgery, and appraises the different minimally invasive colorectal surgical approaches available to date.
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Affiliation(s)
- Mahmoud Abu Gazala
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Shussman N, Kedar A, Elazary R, Abu Gazala M, Rivkind AI, Mintz Y. Reusable single-port access device shortens operative time and reduces operative costs. Surg Endosc 2014; 28:1902-7. [PMID: 24442684 DOI: 10.1007/s00464-013-3411-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 12/20/2013] [Indexed: 01/25/2023]
Abstract
BACKGROUND In recent years, single-port laparoscopy (SPL) has become an attractive approach for performing surgical procedures. The pitfalls of this approach are technical and financial. Financial concerns are due to the increased cost of dedicated devices and prolonged operating room time. Our aim was to calculate the cost of SPL using a reusable port and instruments in order to evaluate the cost difference between this approach to SPL using the available disposable ports and standard laparoscopy. METHODS We performed 22 laparoscopic procedures via the SPL approach using a reusable single-port access system and reusable laparoscopic instruments. These included 17 cholecystectomies and five other procedures. Operative time, postoperative length of stay (LOS) and complications were prospectively recorded and were compared with similar data from our SPL database. Student's t test was used for statistical analysis. RESULTS SPL was successfully performed in all cases. Mean operative time for cholecystectomy was 72 min (range 40-116). Postoperative LOS was not changed from our standard protocols and was 1.1 days for cholecystectomy. The postoperative course was within normal limits for all patients and perioperative morbidity was recorded. Both operative time and length of hospital stay were shorter for the 17 patients who underwent cholecystectomy using a reusable port than for the matched previous 17 SPL cholecystectomies we performed (p < 0.001). Prices of disposable SPL instruments and multiport access devices as well as extraction bags from different manufacturers were used to calculate the cost difference. Operating with a reusable port ended up with an average cost savings of US$388 compared with using disposable ports, and US$240 compared with standard laparoscopy. CONCLUSION Single-port laparoscopic surgery is a technically challenging and expensive surgical approach. Financial concerns among others have been advocated against this approach; however, we demonstrate herein that using a reusable port and instruments reduces operative time and overall operative costs, even beyond the cost of standard laparoscopy.
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Affiliation(s)
- Noam Shussman
- Department of General Surgery, Hadassah-Hebrew University Medical Center, PO Box 12000, 91120, Jerusalem, Israel,
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Bala M, Willner D, Klauzni D, Bdolah-Abram T, Rivkind AI, Gazala MA, Elazary R, Almogy G. Pre-hospital and admission parameters predict in-hospital mortality among patients 60 years and older following severe trauma. Scand J Trauma Resusc Emerg Med 2013; 21:91. [PMID: 24360246 PMCID: PMC3878042 DOI: 10.1186/1757-7241-21-91] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 12/03/2013] [Indexed: 11/10/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Gidon Almogy
- Department of Surgery and Trauma Unit, Hadassah University Hospital, Ein Kerem, pob 12000, Jerusalem, 91120, Israel.
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Abu Gazala M, Shussman N, Abu Gazala S, Schlager A, Elazary R, Ponomernco O, Khalaila A, Rivkind AI, Mintz Y. Miniature Camera for Enhanced Visualization for Single-Port Surgery and NOTES. J Laparoendosc Adv Surg Tech A 2012. [DOI: 10.1089/lap.2012.0124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mahmoud Abu Gazala
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Noam Shussman
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Samir Abu Gazala
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Avraham Schlager
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ram Elazary
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Oleg Ponomernco
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Abed Khalaila
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Avraham I. Rivkind
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Shussman N, Abu Gazala M, Schlager A, Elazary R, Khalaileh A, Zamir G, Kushnir D, Rivkind AI, Mintz Y. Laparoscopic Infrared Imaging—The Future Vascular Map. J Laparoendosc Adv Surg Tech A 2011; 21:797-801. [DOI: 10.1089/lap.2010.0474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Noam Shussman
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mahmoud Abu Gazala
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Avraham Schlager
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Department of Surgery, New York University, New York, New York
| | - Ram Elazary
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Abed Khalaileh
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Gideon Zamir
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - David Kushnir
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Avraham I. Rivkind
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Abu Gazala M, Khalaila A, Shussman N, Abu Gazala S, Elazary R, Amar D, Kushnir D, Ponomernco O, Zamir G, Rivkind AI, Mintz Y. Transesophageal endoscopic myotomy for achalasia: recognizing potential pitfalls before clinical application. Surg Endosc 2011; 26:681-7. [PMID: 21993936 DOI: 10.1007/s00464-011-1937-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 09/13/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Laparoscopic Heller esophagomyotomy is the standard of care for achalasia treatment. This procedure, although effective, must be performed with the patient under general anesthesia and is associated with several serious potential complications. The authors aimed to develop a method of performing transesophageal endoscopic esophagomyotomy (TEEM) that would obviate the need for both general anesthesia and external incisions while offering lower intra- and postoperative complications. METHODS The TEEM procedure was performed on eight pigs. For six of the pigs, the procedure aimed at survival. A mid-esophageal mucosal incision was performed using an endoscope, and a submucosal plane was developed. The lower esophageal sphincter (LES) muscle fibers were clearly visualized and divided. The mucosal incision was closed using fibrin sealant. After 2 weeks of survival, a gastrografin swallow study and necropsy were performed. RESULTS The TEEM procedure was performed successfully in all eight porcine models. The myotomy included the LES fibers and extended 4 to 6 cm proximally to the esophagus. The proximal gastric muscle was divided up to 1 to 2 cm. No injuries to the abdominal or mediastinal structures occurred. One pig died on postoperative day 1 due to an unrecognized pneumothorax. Two pigs had ischemic ulcers at the myotomy site. The last three pigs had an uneventful recovery. The mucosal incision site healed completely in all the survived pigs, and except for the pig with mediastinal sepsis, all ate heartily and gained weight as expected. CONCLUSION The TEEM procedure is technically feasible. Due to the morbidity encountered in the first three pigs, the reported technique was modified to include a slimmer endoscope, a shorter tunnel, and a partial-thickness myotomy. These changes together with an understanding of the pitfalls involved in this procedure led to successful results for the next three pigs. Nevertheless, the authors believe that TEEM is not yet ready for prime time. Perfection of the technique and development of dedicated instruments are mandatory before safe translation of this method to human patients.
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Affiliation(s)
- Mahmoud Abu Gazala
- Department of General Surgery, Hadassah Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel.
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Schlager A, Khalaileh A, Mintz Y, Abu Gazala M, Globerman A, Ilani N, Rivkind AI, Salpeter S, Dor Y, Zamir G. A mouse model for sleeve gastrectomy: applications for diabetes research. Microsurgery 2010; 31:66-71. [PMID: 20734435 DOI: 10.1002/micr.20797] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 04/11/2010] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Discovery of enhanced glucose tolerance following bariatric surgery has sparked renewed interest in the investigation of unchartered underlying pathways of glucose homeostasis. Delineation of this pathway may ultimately be the first step in the creation of a novel therapy for type II diabetes. Nevertheless, the technical complexity and formidable nature of these surgeries coupled with the fragile nature of small rodents has made the creation of a mouse model to study these effects incredibly challenging. We have created a simplified sleeve gastrectomy mouse model to study the effects of bariatric surgery on glucose tolerance and beta cell proliferation. METHODS Nineteen mice were randomized to undergo either sleeve gastrectomy (SG) (9) or sham operation (SH) (10). Weight and serum glucose were measured three times weekly and serum insulin measurements and pancreatic harvest were performed at the time of sacrifice. Five mice from each group were sacrificed after one week and the remainder sacrificed after one month. RESULTS Survival of mice was 100% for both groups. The SG group demonstrated an initial drop in weight and serum glucose as compared to SH, which normalized by one month following surgery. Serum insulin levels and rate of beta cell proliferation were similar in both groups after one week and one month. CONCLUSION The simplified sleeve gastrectomy is a technically straightforward, low-mortality technique for creating a bariatric mouse model which most faithfully replicates bariatric surgery performed in humans. This model can be a valuable tool to investigate the glucose tolerance and beta cell effects of bariatric surgery.
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Affiliation(s)
- Avraham Schlager
- Department of Surgery, New York University Medical Center, NY, USA.
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