BACKGROUND:Surgical myotomy is the best therapeutic option for patients with achalasia. The minimally invasive technique is considered to be the preferred method for many surgeons. Robotic-assisted laparoscopic myotomy has several advantages over conventional laparoscopic surgery. These benefits include more accurate incisions that may result in a lower rate of intra-operative complications.OBJECTIVES:To describe our technique of performing robotic-assisted Heller myotomy and to review the initial results of this procedure.METHODS:All patients undergoing robotic-assisted Heller myotomy for achalasia between the years 2012-2018 at Rabin Medical Center were retrospectively reviewed from our institutional prospective database.RESULTS:Thirty patients underwent robotic-assisted Heller myotomy for achalasia. Mean operative time was 77 minutes (range 47-109 minutes) including docking time of the robotic system. There were no cases of conversion to laparoscopic or open surgery. There were no cases of intra-operative perforation of the mucosa. None of the patients had postoperative morbidity or mortality. Good postoperative results were achieved in 25 patients. Four patients required additional intervention (3 had endoscopic dilatations and 1 with known preoperative endstage achalasia had undergone esophagectomy). One patient was lost to follow-up.CONCLUSIONS:Robotic-assisted Heller myotomy is a safe technique with a low incidence of intra-operative esophageal perforation compared to the laparoscopic approach. We believe that robotic-assisted surgery should be the procedure of choice to treat achalasia.

BACKGROUND Older age is an independent predictor of worse outcome from traumatic brain injury (TBI). No clear guidelines exist for the management of TBI in elderly patients. OBJECTIVES To describe the outcomes of elderly patients presenting with TBI and intracranial bleeding (ICB), comparing a very elderly population (≥ 80 years of age) to a younger one (70-79). METHODS Retrospective analysis of the outcomes of elderly patients presenting with TBI with ICB admitted to a level I trauma center. RESULTS The authors analyzed 100 consecutive patients aged 70-79 and 100 patients aged 80 and older. In-hospital mortality rates were 9% and 21% for groups 70-79 and ≥ 80 years old, respectively (P = 0.017). Patients 70-79 years old showed a 12-month survival rate of 73% and a median survival of 47 months. In patients ≥ 80 years old, 12-month survival was 63% and median survival was 27 months (P = NS). In patients presenting with a Glasgow Coma Scale score of ≥ 8, the in-hospital mortality rates were 41% (n=5/12) and 100% (n=8/8). Among patients ≥ 80 years old undergoing emergent surgical decompression, in-hospital mortality was 66% (n=12/18). Survivors presented with a severe drop in their functional score. Survival was dismal in patients ≥ 80 years old who were treated conservatively despite recommended operative guidelines. CONCLUSIONS There is a lack of reliable means to evaluate the outcome in patients with poor functional status at baseline. The negative prognostic impact of severe TBI is profound, regardless of treatment choices.

BACKGROUND:Unlike the elective treatment of metastatic colorectal cancer (MCRC), sufficient data and consensual guidelines on acute care are lacking.OBJECTIVES:To analyze a cohort of MCRC patients who required urgent surgery due to acute abdomen and to identify risk factors contributing to the patient's perioperative mortality and morbidity.METHODS:A retrospective analysis was conducted of patients diagnosed with stage IV colorectal cancer who required urgent laparotomy at the Rabin Medical Center. Comparative analysis was performed using Pearson's chi-square and Student`s t-test.RESULTS:Between 2010 and 2015, 113 patients underwent urgent laparotomy due to colorectal cancer complications, of which 62 patients were found to have a metastatic, stage IV, disease. Large bowel obstruction was the most common indication for urgent laparotomy. In-hospital mortality was 30% (n=19), and overall 30 day mortality was 43%. Fifteen patients (24%) required more than one surgery. The average length of hospital stay was 21 days. Age and lactate levels at presentation were the only prognostic factor found for mortality (P < 0.05).CONCLUSIONS:MCRC laparotomy patients incur a significant burden of care and have a relatively high incidence of early mortality. Our data suggest high, verging on unacceptable, mortality and complication rates in this subgroup of patients. This finding is further accentuated in the subgroup of older patients presenting with lactatemia. These data should be considered by surgeons when discussing treatment options with patients and families.

BACKGROUNDSpinal injury is common in trauma suffered by both men and women. A lesser degree of involvement of females with spinal trauma, or at least, the different nature of such injuries, has been suggested. It has been proposed that behavioral and structural characteristics may explain the differential type and severity of spinal injuries in women. We carried out this study to find women-specific divergences in spinal traumatic lesions, including suspected mechanisms for their generation.METHODSAll patients with spinal injury, documented by the Trauma Registry at our Medical Center and using the AIS code 65XXXX.X for spinal fractures and dislocations, were evaluated. The women-associated analysis included data related to: type of spinal lesion, area affected, possible mechanisms, associated damage, surgical procedures, and complications. Male-related data were collected for comparison.RESULTSBetween 2006 and 2010, 546 patients with traumatic spine injuries were documented. Of those, 30.6% were women (F:M-168:378). Average age was 43.5 years (women: 49.6 years and men: 40.1 years). Regarding the mechanisms of injury, women with spinal injuries were susceptible to falls from a standing position or had attempted suicide. However, men with similar lesions had a tendency to be more involved in motorcycle accidents or falls from height. Women involved in motor vehicle crashes showed statistically more significant lumbar spine lesions, whereas men in the same situation developed mainly cervical spine damage to a significant level.CONCLUSIONSThe characteristics of spinal injury in women, as opposed to men, stand out as divergent. The mechanisms of trauma and the site of injury differ significantly. We suggest this variance may be due, in part, to skeletal and muscular structure dissimilarity in women and in part to the spinal kinematics attending each group.

AIM:To assess the incidence and injury characteristics of hospitalized trauma patients diagnosed with TBI.METHODS:A retrospective study of all injured hospitalized patients recorded in the National Trauma Registry at 19 trauma centres in Israel between 2002-2011. Incidence and injury characteristics were examined among children, adults and seniors.RESULTS:The annual incidence rate of hospitalized TBI for the Israeli population in 2011 was 31.8/100,000. Age-specific incidence was highest among seniors with a dramatic decrease in TBI-related mortality rate among them. Adults, in comparison to children and seniors, had higher rates of severe TBI, severe and critical injuries, more admission to the intensive care unit, underwent surgery, were hospitalization for more than 2 weeks and were discharged to rehabilitation. After adjusting for age, gender, ethnicity, mechanism of injury and injury severity score, TBI-related in-hospital mortality was higher among seniors and adults compared to children.CONCLUSION:Seniors are at high risk for TBI-related in-hospital mortality, although adults had more severe and critical injuries and utilized more hospital resources. However, seniors showed the most significant reduction in mortality rate during the study period. Appropriate intervention programmes should be designed and implemented, targeted to reduce TBI among high risk groups.

Objective: Systolic anterior motion (SAM) after mitral valve repair with significant mitral regurgitation requires immediate reintervention. Transient SAM immediately after repair is usually managed by hemodynamic maneuvers. We investigated the late clinical and echocardiographic significance of postoperative transient SAM.Methods: Between 2004 and 2013, mitral valve repair was performed on 549 consecutive patients with degenerative mitral valve disease. Of the 45 patients (8.2%) identified with postrepair SAM, 5 needed immediate reintervention. Hemodynamic maneuvers, such as preload and afterload augmentation and rate control, effectively abolished SAM in 40 patients (SAM). They were followed and compared with the remaining 509 patients (non-SAM).Results: Mean clinical follow-up was 54 +/- 28 and 31 +/- 26 months and was available in 100% and 95%(SAM and non-SAM) patients, respectively. One hospital death occurred in each group (P = .14). At follow-up, 2 patients (0.3%) showed significant SAM with left ventricular outflow tract obstruction, which resolved in 1 patient after beta-blocker therapy. SAM patients underwent exercise stress echocardiography: 1 patient showed left ventricular outflow tract obstruction that worsened after exercise. At 5 years, freedom from moderate or severe mitral regurgitation and New York Heart Association functional class III-IV was 85% versus 92%(P = .27) and 81% versus 92%(P = .15), and freedom from reoperation was 100% and 96% (P = .4), in SAM and non-SAM patients, respectively.Conclusions: Late postoperative exercise stress echocardiogram revealed low incidence of SAM in patients with immediate postrepair transient SAM. All other late clinical outcomes were similar to those of non-SAM repair patients. Conservative management of intraoperative transient SAM is both successful and reliable.

Severe injury triggers a complex systemic immune response which may result in significant respiratory compromise, including the development of acute respiratory distress syndrome (ARDS). No randomized clinical trial has assessed the role of nutritional interventions to limit respiratory complications.

Objectives: Inappropriate distribution of casualties in mass-casualty incidents (MCIs) may overwhelm hospitals. This study aimed to review the consequences of evacuating casualties from a bus accident to a single peripheral hospital and lessons learned regarding policy of casualty evacuation.Methods: Medical records of all casualties relating to evacuation times, injury severity, diagnoses, treatments, resources utilized and outcomes were independently reviewed by two senior trauma surgeons. In addition, four senior trauma surgeons reviewed impact of treatment provided on patient outcomes. They reviewed the times for the primary and secondary evacuation, injury severity, diagnoses, surgical treatments, resources utilized, and the final outcomes of the patients at the point of discharge from the tertiary care hospital.Results: Thirty-one survivors were transferred to the closest local hospital; four died en route to hospital or within 30 minutes of arrival. Twenty-seven casualties were evacuated by air from the local hospital within 2.5 to 6.15 hours to Level I and II hospitals. Undertriage of 15% and overtriage of seven percent were noted. Four casualties did not receive treatment that might have improved their condition at the local hospital.Conclusions: In MCIs occurring in remote areas, policy makers should consider revising the current evacuation plan so that only immediate unstable casualties should be transferred to the closest primary hospital. On site Advanced Life Support (ALS) should be administered to non-severe casualties until they can be evacuated directly to tertiary care hospitals. First responders must be trained to provide ALS to non-severe casualties until evacuation resources are available.

Background The CD24 gene has been correlated with poor prognosis of various malignancies. The significance of CD24 in esophageal cancer remains unknown. Our aim was to evaluate the association between CD24 genetic polymorphism and esophageal cancer. Materials and Methods Between June 2011 and May 2012 patients with esophageal cancer and healthy controls were prospectively enrolled and clinicopathological data were collected. Genomic DNA was extracted and restriction fragment length polymorphism (RFLP) analysis was performed to determine CD24 polymorphism at the coding region of CD24, which results in a substitution of the amino acid Ala by Val. Statistical significance was determined by unpaired t-test, χ2-test, and Fisher's exact test. Results A total of 102 patients were included, of whom 51 had esophageal cancer and the rest comprised a healthy control group. The incidence of the polymorphism variant (Val/Val) among the healthy subjects and the esophageal cancer cohort was 6% in both groups. The incidence of N3 (metastasis in 7 or more regional lymph nodes) was markedly higher in those esophageal cancer patients who carried the polymorphism variant compared with those who did not carry it (66% and 2%, respectively, p=0.007). No significant difference was found between the groups with regard to age, gender, histology type, tumor location, tumor stage, and other histological characteristics of the tumor. Conclusions This CD24 polymorphism may serve as a novel prognostic marker identifying esophageal cancer patients with poor prognosis. Further studies are warranted to evaluate CD24 function and to validate its predictive potential with regard to esophageal cancer.

lymph nodes was seen with increasing tumor length (p<0.001) in all patients, while no difference was seen in total lymph nodes harvested.Conclusion: The findings of this study suggest an important association between esophageal cancer tumor length and regional lymph node metastasis as well as overall survival.Future clinical staging of esophageal cancer may benefit from adding tumor length to current methods relying on depth of invasion (T status) and an estimation of positive lymph nodes from CT or EUS (N status).

Case report. Transcatheter arterial embolization is an interventional radiological procedure that is increasingly used to stop bleeding particularly in trauma. As previous reports allude to paraplegia complicating this procedure in blunt trauma, we describe a complication of this procedure following penetrating trauma to the posterior trunk. A 21 year old male sustained a stab wound to the back with profuse bleeding. CT angiography showed a bleeding paraspinal branch of the 10th intercostal artery, for which he had intercostal embolization using Embozene® 500 μm. Although hemostasis was achieved immediately, the patient developed weakness in both lower limbs shortly after the procedure and rapidly progressed to complete cord injury with sensory level at T10. Transcatheter embolization of the intercostal artery, though safe and effective, may be accompanied by a complete and permanent spinal cord injury. It is probably best avoided where it would involve embolizing vessels close to the origin of the artery of Adamkiewicz (T8–T11) and situations where it will involve embolizing the vessel in proximity to its origin in the midline. In the haemodynamically stable patient with penetrating injury, other options including wound exploration should be considered.

BACKGROUND:The use of extracorporeal life support in trauma casualties is limited by concerns regarding hemorrhage, particularly in the presence of traumatic brain injury (TBI). We report the use of extracorporeal membrane oxygenation (ECMO)/interventional lung assist (iLA) as salvage therapy in trauma patients. High-flow technique without anticoagulation was used in patients with coagulopathy or TBI.METHODS:Data were collected from all adult trauma patients referred to one center for ECMO/iLA treatment owing to severe hypoxemic respiratory failure.RESULTS:Ten casualties had a mean (SD) Injury Severity Score (ISS) of 50.3 (10.5) (mean [SD] age, 29.8 [7.7] years; 60% male) and were supported 9.5 (4.5) days on ECMO (n = 5) and 7.6 (6.5) days on iLA (n = 5). All experienced blunt injury with severe chest injuries, including one cardiac perforation. Most were coagulopathic before initiation of ECMO/iLA support. Among the seven patients with TBI, four had active intracranial hemorrhage. Complications directly related to support therapy were not lethal; these included hemorrhage from a cannulation site (n = 1), accidental removal of a cannula (n = 1), and pressure sores (n = 3). Deaths occurred owing to septic (n = 2) and cardiogenic shock (n = 1). Survival rates were 60% and 80% on ECMO and iLA, respectively. Follow-up of survivors detected no neurologic deterioration.CONCLUSION:ECMO/iLA therapy can be used as a rescue therapy in adult trauma patients with severe hypoxemic respiratory failure, even in the presence of coagulopathy and/or brain injury. The benefits of rewarming, acid-base correction, oxygenation, and circulatory support must be weighed individually against the risk of hemorrhage. Further research should determine whether ECMO therapy also confers survival benefit.LEVEL OF EVIDENCE:Therapeutic study, level V.

Previous analyses of the safety of the conservative versus the operative approach to the treatment of liver and spleen blunt injuries in children often failed to account for differences in quality of care and expertise among dedicated pediatric trauma center, non-pediatric centers, centers without trauma units, and non-trauma centers. To eliminate this potential bias, the present study examined changes in the rate of surgery and their impact on outcome within the same medical centers over time.

BACKGROUND:In recent years, laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. Of continuing concern are the rate of postoperative complications and the lack of consensus as to surgical technique.METHODS:A prospective study assessment was made of 120 consecutive morbidly obese patients with body mass index (BMI) of 43+/-5 (30 to 63), who underwent LSG using the following technique: (1) division of the vascular supply of the greater gastric curvature and application of the linear stapler-cutter device beginning at 6-7 cm from the pylorus so that part of the antrum remains; (2) inversion of the staple line by placement of a seroserosal continuous suture close to the staple line; (3) use of a 48 Fr bougie so as to avoid possible stricture; (4) firing of the stapler parallel to the bougie to make the sleeve as narrow as possible and prevent segmental dilatation.RESULTS:Intraoperative difficulties were encountered in four patients. There were no postoperative complications-no hemorrhage from the staple line, no anastomotic leakage or stricture, and no mortality. In 20 patients prior to the sleeve procedure, a gastric band was removed. During a median follow-up of 11.7 months (range 2-31 months), percent of excess BMI lost reached 53+/-24% and the BMI decreased from 43+/-5 to 34+/-5 kg/m(2). Patient satisfaction scoring (1-4) at least 1 year after surgery was 3.6+/-0.8.CONCLUSIONS:The good early results obtained with the above-outlined surgical technique in 120 consecutive patients undergoing LSG indicate that it is a safe and effective procedure for morbid obesity. However, long-term results are still pending.