[THE VALUE OF MUSCLE BIOPSY IN PATIENTS WITHOUT WEAKNESS, HIGH CREATINE KINASE OR MYOPATHY ON ELECTROMYOGRAPHY].

INTRODUCTION: Muscle biopsy is an important diagnostic procedure for the evaluation of neuromuscular disorders, commonly employed when patients present with muscle weakness, high creatine-kinase or electromyography which suggest myopathy. The diagnostic value of this procedure when these are normal is unclear. AIMS: To characterize the pathology in muscle biopsies of patients without clinical, laboratory or electromyographic suggestion for myopathy. METHODS: Retrospective chart and pathology review of consecutive patients who were evaluated by muscle biopsy at Sheba Medical Center. RESULTS: Of 109 patients, 12 (11%) had no indication for myopathy prior to biopsy. Pathology was identified in 2/3 of cases. Inflammation was detected in 5 cases (42%), with a perivascular infiltrate in four, and endomysial in one. A mild myopathy was present in 3/5 of these cases. Type-2 muscle fiber atrophy as the primary or only pathology was seen in 2 cases (17%) and mild neurogenic changes in one (8%). A history of systemic disease, additional laboratory tests or imaging suggestive for inflammation were predictive for inflammatory pathology in 4/5 of cases (P = 0.006). CONCLUSIONS: Perivascular inflammation without significant muscle fiber damage is common and meaningful in patients with inflammatory conditions in spite of normal evaluation for myopathy. DISCUSSION: Muscle disease is characterized by damage to muscle fibers, connective tissue or vessels. In the absence of fiber damage, muscle strength, creatine-kinase and electromyography may remain normal. These tests therefore do not rule-out perivascular inflammation and mild myopathy. Muscle biopsy is effective for the detection of inflammation in patients with inflammatory conditions in spite of normal strength creatine-kinase and electromyography.

[CYTOREDUCTIVE SURGERY AND HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY FOR PERITONEAL CARCINOMATOSIS OF COLORECTAL ORIGIN - FIRST 100 CASES].

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an effective treatment for selected patients with peritoneal carcinomatosis of colorectal origin. We present our experience with the first 100 consecutive cases of this combined treatment. METHODS: CRS/HIPEC procedures were performed between 4/2009-8/2016. HIPEC was initially delivered using the "Open" abdomen technique; beginning in January 2014, HIPEC was delivered using the "Closed" technique. As a chemotherapeutic agent we used Mitomycin-C, perfused for duration of 90 minutes at 41 degrees Celsius. RESULTS: A total of 100 procedures were performed in 94 patients (64% females, median age 62 (22-83) years) with colon (n=89) or rectal (n=5) cancer. Complete cytoreduction (CC score≤1) was achieved in 91 procedures. The average duration of surgery was 7.5±2.3 hours, the median number of organs resected was 2 (0-6) and the median length of hospital stay was 9 (5-101) days. Postoperative complications occurred in 54% of procedures and the incidence of major complications (Clavien-Dindo 3-4) was 12%. Three patients (3%) died within 90 days postoperatively. Higher peritoneal cancer index (PCI) score, higher number of organs resected/anastomoses created and longer duration of surgery were associated with perioperative morbidity (all p≤0.05). The median follow-up period was 2.1 years during which 50 patients died. The median overall survival (OS) and disease free survival were 3.1 years and 10.7 months, respectively; 7 patients survived ≥5 years after surgery. Higher PCI score and occurrence of major postoperative complications were associated with poorer OS. CONCLUSIONS: CRS/HIPEC for peritoneal carcinomatosis of colorectal cancer origin is feasible and safe. This treatment may benefit selected patients in terms of OS.

Assessment of gel-coated delayed self-gripping mesh.

BACKGROUND: Mesh hernia repair is one of the most frequently performed procedures in general surgery. Recently, use of the self-gripping mesh demonstrated a beneficial effect on postoperative pain in inguinal hernia repairs. However, in intra-abdominal placement, the use of this novel mesh requires greater laparoscopic skill and dexterity because of the mesh's tendency to fold and adhere to itself and to any surrounding tissues. We hypothesized that gel-like coverage of a self-gripping mesh with a water-soluble film would allow delaying the immediate surface adhesion of the mesh to the tissue, which may allow greater freedom and ease in mesh placement for laparoscopic surgeons. METHODS: In this ex vivo animal study, gel-coated self-gripping mesh (ProGrip) was compared with a control uncoated mesh in bovine and porcine tissue specimens and assessed for dislodgement shear forces before and after dissolving of the gel. RESULTS: Gel coating of the mesh reduced preperitoneal dislodgement forces in a porcine abdominal wall specimen by 81% (8.05 ± 0.66 vs 1.53 ± 0.82 N, P < .01). Dissolving the gel markedly increased the anchoring forces (10.62 ± 3.70 vs 1.53 ± 0.82 N, P < .0001), and after dissolving the gel, the mesh shear dislodgement forces were similar and noninferior to the control mesh (8.05 ± 0.66 vs 10.62 ± 3.70 N, P = NS). CONCLUSIONS: We believe that water-soluble gel coating does not impair the adhesive features of the self-gripping mesh and may simplify its use in open and laparoscopic procedures by allowing controlled activation of the self-gripping mechanism.

[Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal and appendiceal origin].

BACKGROUND: We report our initial experience combining cytoreductive surgery (CRS) plus intraperitoneal chemotherapy with hyperthermia (HIPEC) in a selected group of patients presenting with disseminated peritoneal carcinomatosis (PC) of colorectaL or appendiceaL origin at a single tertiary referral institution. METHODS: The study included patients who underwent CRS with HIPEC at the Sheba Medical Center between April 2009 and December 2011. The HIPEC technique was administered with the open Coliseum technique reaching a steady state of mitomycin-C delivery at 410 C for perfusion duration of 90 minutes. RESULTS: AnaLysis included 45 patients (18 males) incorporating 42 cases of primary colorectal cancer (CRC) or appendiceal cancer and 3 cases of pseudomyxoma peritonei. Thirty-seven patients (82%) underwent CC-0 resections with a median overall hospital stay of 8 days (range 5-43). There was one perioperative death at 90 days. The perioperative complication rate was 31.1%. The median follow-up was 12 months (range 2-36) during which 13 patients died. Among the CRC and appendiceal cancer group the median overall survival was 20.2 months and the median progression free survival was 16.4 months (Kaplan-Meier analysis). During follow-up, 23 patients experienced disease progression. CONCLUSION: The selective use of cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for patients with peritoneal carcinomatosis from colorectal or appendiceal origin is safe with acceptable morbidity and low mortality.

Laparoscopic resection of rectal cancer.

BACKGROUND: The treatment of rectal cancer has changed significantly over the last few decades. Advanced surgicil techniques have led to an increase in the rate of sphincter-preserving operations, even for low rectal tumors. This was facilitated by preoperative oncologic treatment and the use of chemoradiation to downstage the tumor before resection. The introduction of total mesorectal excision further improved the oncologic outcome and became the standard of care. The use of laparoscopy for rectal resection is the most recent addition to this series of improvements, but in contrast to the use of laparoscopy in colon cancer its role is not yet well defined. OBJECTIVES: To present our experience with laparoscopic surgery for upper and lower rectal tumors. METHODS: A database was used to prospectively collect all data on laparoscopic rectal surgery in our department since we started performing these procedures in 1997. Follow-up data were collected from outpatient clinic visits, oncology files and telephone interviews. Updated survival data were retrieved from the national census. RESULTS: Of 750 laparoscopic colorectal procedures performed over a 13 year period, 67 were for rectal cancer. Of these, 29 were resections for tumors in the upper rectum (11-15 cm from the analverge) and 38 for tumors at 10 cm or below. Surgery was performed in 24 patients after neoadjuvant chemoradiation. There were 54 sphincter-preserving operations and 13 abdominoperineal resections. The mean operative time was 283 minutes. Conversion to an open procedure was required in 22% of the cases. Anastomotic leaks occurred in 17% of cases. Postoperative mortality was 4.5%. Long-term follow-up was available for 77% of the group, for a mean period of 42 months. Local recurrence was diagnosed in 4.5% of the patients and overall 5 year survival was 68%. CONCLUSIONS: Laparoscopic rectal resection is a demanding procedure. However, laparoscopy may become the preferred approach since it is a minimally invasive procedure and has an acceptable oncologic outcome that is comparable to that with the open approach. This conclusion, however, needs further validation.

Long-term results of local excision for T1 rectal carcinoma: the experience of two colorectal units.

BACKGROUND: Local excision for early rectal cancer has low morbidity and good functional results. Its use is limited by the inability to assess regional lymph nodes and by the uncertainty of oncologic outcome. METHODS: We conducted a retrospective chart review of all patients who underwent local excision of early rectal cancer in two colorectal units between 1995 and 2007. The retrieved and analyzed data were patient age and gender, tumor size, tumor distance from the anal verge, tumor differentiation, and additional treatment. RESULTS: There were 42 patients with T1 rectal cancer: 24 underwent transanal endoscopic microsurgery and 18 had a transanal excision. The surgical margins were free of tumor in 39 patients (93%), they were involved by tumor in one (2%) and margin status was unclear in two (5%). Seven patients (16%) had postoperative complications. There was no postoperative mortality. The mean hospital stay was 67 h. Thirty-nine patients (93%) were followed up for 57 months (mean). Two patients had local recurrence, at 7 and 41 months post-surgery. They had a tumor that invaded into the lower third of the submucosa, sm3. Both received chemoradiotherapy, and underwent an abdominoperineal resection and a low anterior resection. One of them died of metastatic disease 13 months later and the other is alive with no evidence of disease. Another two patients had salvage low anterior resection, one for suspected local recurrence and one for lymphovascular invasion: the specimens were tumor free. Six patients died of unrelated causes. CONCLUSIONS: Local excision of early rectal cancer is a feasible and acceptable alternative to radical resection. It has low complication and recurrence rates and a short postoperative hospital stay.

Laparoscopic colectomy without mechanical bowel preparation.

BACKGROUND: Mechanical bowel preparation prior to colorectal surgery may reduce infectious complications, facilitate tumor localization, and allow intraoperative colonoscopy, if required. However, recent data suggest that mechanical bowel preparation may not facilitate a reduction in infectious complications. During laparoscopic colectomy, manual palpation is blunt, thereby potentially compromising tumor localization. The aim of this study was to assess the utility of mechanical bowel preparation in laparoscopic colectomy. MATERIALS AND METHODS: A retrospective medical record review of all patients who underwent laparoscopic colectomy was performed. Patients were divided into two groups: those who had preoperative mechanical bowel preparation (Group A) or those who did not (Group B). All relevant perioperative data were reviewed and compared. RESULTS: Two hundred patients underwent laparoscopic colectomy; 68 (34%) were in Group A and 132 (66%) were in Group B. Sixteen (8%) patients required intraoperative colonoscopy for localization and were evenly distributed between the two groups. The incidence of conversion to laparotomy was slightly higher in Group B (14 vs 9%) due to difficult localization in some cases; however, this difference did not reach statistical significance. Furthermore, there was no significant difference in the postoperative complication rate between the two groups. Specifically, an anastomotic leak and a wound infection were recorded in 4 and 12% of patients in Group A compared to 3 and 17% in Group B, respectively. CONCLUSIONS: Laparoscopic colectomy may be safely performed without preoperative mechanical bowel preparation, although difficult localization may lead to a slightly higher conversion rate. Appropriate patient selection for laparoscopic colectomy without mechanical bowel preparation is essential. Furthermore, bowel preparation should be considered in cases of small and nonpalpable lesions.