Israel Medical Association Journal

Background: Pilonidal sinus is a chronic, inflammatory condition. Controversy exists regarding the best surgical  management for pilonidal sinus, including the extent of excision and type of closure of the surgical wound.

Objectives: To assess the short- and long-term outcomes and success rate of the trephine procedure for the treatment of pilonidal sinus.

Method: A retrospective observational cohort study was conducted at a single center. Patients who underwent trephine procedure between 2011 and 2015 were included. Data collection included medical records review and a telephone interview to establish long-term follow-up.

Results: A total of 169 patients underwent the trephine technique for the repair of pilonidal sinus. Follow-up included 113 patients, median age 20 years. Initial postoperative period, 35.6% recalled no pain and 58.6% reported a mild to moderate pain. Postoperative complications included local infection (7.5%) and mild bleeding (15.1%). On early postoperative follow-up, 47.1% recalled no impairment in quality of life, and 25%, 21.2 %, and 6.7% had mild, moderate and sever disturbance respectively. The median time to return to work or school was 10 days. At a median follow-up of 29 months (IQR 19–40), recurrence rate was 45.1% (51/113), and 38 (33.9%) of the patients underwent another surgical procedure. Overweight, smoking, and family history were associated with higher recurrence rate.

Conclusion: The trephines technique has a significant long-term recurrence rate. Short-term advantages include low morbidity, enhanced recovery, and minimal to mild postoperative impairment to quality of life. The trephine procedure may be justified as a first treatment of pilonidal disease

Background: A paraovarian cyst (POC) is located between the ovary and the fallopian tube. In many cases POCs are diagnosed and managed as ovarian cysts. But since POC are a distinct entity in their clinical presentation and surgical intervention, they should be better defined.

Objectives: To describe the clinical perioperative and operative characteristics of patients with POCs in order to improve pre-operative diagnosis and management.

Methods: A retrospective cohort study of patients with an operative diagnosis of POC between 2007 and 2019 in a single university-affiliated tertiary care medical center was included. Demographic characteristics as well as symptoms, sonographic appearance, surgery findings, and histology results were retrieved from electronic medical records.

Results: During the study period 114 patients were surgically diagnosed with POC, 57.9% were in their reproductive years and 24.6% were adolescents. Most presented with abdominal pain (77.2%). Preoperative sonographic exams accurately diagnosed POC in only 44.7% of cases, and 50.9% underwent surgery due to suspected torsion, which was surgically confirmed in 70.7% of cases. Among women with confirmed torsion, 28.9% involved the fallopian tube without involvement of the ipsilateral ovary. Histology results showed benign cysts in all cases, except two, with a pathological diagnosis of serous borderline tumor.

Conclusions: POC should always be part of the differential diagnosis of women presenting with lower abdominal pain and sonographic evidence of adnexal cysts. If POC is suspected there should be a high level of suspicion for adnexal torsion and low threshold for surgical intervention, especially in adolescent, population who are prone to torsion

Background: Ureteroscopy is becoming the primary treatment for ureteral stones. As a standard of care, ureteroscopy is performed under the supervision of fluoroscopy. Recent advances in endourological technology make the need for fluoroscopy questionable.

Objectives: To summarize our experience with a no-fluoroscopy technique for selected cases of ureteral stones.

Methods: Patients were considered suitable for fluoroless ureteroscopy if they had one or two non-impacted stones, in any location in the ureter, 5–10 mm size, with a normal contralateral renal unit and no urinary tract infection. Procedures were performed using rigid scopes, nitinol baskets/forceps for stone retrieval, and Holmium:YAG laser for lithotripsy. Stents were placed per surgeon's decision.

Results: During an 18-month period, 103 patients underwent fluoroless ureteroscopy. In 94 patients stones were removed successfully. In six, the stones were pushed to the kidney and treated successfully on a separate session by shock wave lithotripsy. In three patients no stone was found in the ureter. In five patients, miniature perforations in the ureter were noted and an indwelling double J stent was placed.

Conclusions: Fluoroless ureteroscopy resulted in a high rate of success. We believe that in selected cases it can be used with minimal adverse events

Background: Patients with high-risk prostate cancer are at higher risk of treatment failure, development of metastatic disease, and mortality. There is no consensus on the treatment of choice for these patients, and either radical prostatectomy (RP) or external beam radiation therapy (EBRT) is recommended. Surgery is less common as the initial treatment for high-risk patients, possibly reflecting the concerns regarding morbidity as well as oncological and functional outcomes. Another high-risk group includes patients with failure of previous EBRT or focal treatment. For these patients, salvage radical prostatectomy (SRP) can be offered.

Objectives: To describe our experience with surgery of high-risk patients and SRP.

Methods: This cohort included all high-risk patients undergoing RP or SRP at our institution between January 2012 and December 2019. We reviewed the electronic medical charts and collected pathological, functional, and oncological outcomes.

Results: Our cohort included 39 patients; average age was 67.8 years, and average follow-up duration was 40.9 months. The most common postoperative morbidity was transfusion of packed cells. There were no life-threatening events or postoperative mortality. Continence was preserved (zero to one pad) in 76% of the patients. Twenty-three patients (59%) had undetectable prostate specific antigen levels following the surgery, 11 (30%) were treated with either adjuvant or salvage EBRT, and 12 patients (31%) were found with no evidence of disease and no additional treatment was needed.

Conclusions: Radical prostatectomy and SRP are safe options for patients presenting with high-risk prostate cancer, with good functional and oncological outcomes.

Background: Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations, but currently no data is available about the prevalence and prognostic implication of TR in ST-segment elevation myocardial infarction (STEMI) patients.

Objectives: To investigate the possible implication of TR among STEMI patients.

Methods: We conducted a retrospective study of STEMI patients undergoing primary percutaneous coronary intervention (PCI) and its relation to major clinical and echocardiographic parameters. Patient records were assessed for the prevalence and severity of TR, its relation to the clinical profile, key echocardiographic parameters, in-hospital outcomes, and long-term mortality. Patients with previous myocardial infarction or known previous TR were excluded.

Results: The study included 1071 STEMI patients admitted between September 2011 and May 2016 (age 61 ± 13 years; predominantly male). A total of 205 patients (19%) had mild TR while another 32 (3%) had moderate or greater TR. Patients with significant TR demonstrated worse echocardiographic parameters, were more likely to have in-hospital complications, and had higher long-term mortality (28% vs. 6%; P < 0.001). Following adjustment for significant clinical and echocardiographic parameters, mortality hazard ratio of at least moderate to severe TR remained significant (hazard ratio 2.44; 95% confidence interval 1.06–5.62; P = 0.036) for patients with moderate-severe TR.

Conclusions: Among STEMI patients after primary PCI, the presence of moderate-severe TR was independently associated with adverse outcomes and significantly lower survival rate

Background: For locally advanced rectal cancer patients a watch-and-wait strategy is an acceptable treatment option in cases of complete tumor response. Clinicians need robust methods of patient selection after neoadjuvant chemoradiation.

Objectives: To predict pathologic complete response (pCR) using computer vision. To analyze radiomic wavelet transform to predict pCR.

Methods: Neoadjuvant chemoradiation for patients with locally advanced rectal adenocarcinoma who passed computed tomography (CT)-based simulation procedures were examined. Gross tumor volume was examind on the set of CT simulation images. The volume has been analyzed using radiomics software package with wavelets feature extraction module. Statistical analysis using descriptive statistics and logistic regression was performed was used. For prediction evaluation a multilayer perceptron algorithm and Random Forest model were used.

Results: In the study 140 patients with II–III stage cancer were included. After a long course of chemoradiation and further surgery the pathology examination showed pCR in 38 (27.1%) of the patients. CT-simulation images of tumor volume were extracted with 850 parameters (119,000 total features). Logistic regression showed high value of wavelet contribution to model. A multilayer perceptron model showed high predictive importance of wavelet. We applied random forest analysis for classifying the texture and predominant features of wavelet parameters. Importance was assigned to wavelets.

Conclusions: We evaluated the feasibility of using non-diagnostic CT images as a data source for texture analysis combined with wavelets feature analysis for predicting pCR in locally advanced rectal cancer patients. The model performance showed the importance of including wavelets features in radiomics analysis.

Background: Hip fracture is common in elderly patients and is associated with high morbidity and mortality. Acute kidney injury (AKI) following hip fracture may have additional impact on clinical outcomes.

Objectives: To investigate the incidence of AKI, the risk factors for its occurrence and impact on mortality, timing of surgery, and length of hospitalization (LOS) in patients undergoing hip fracture surgery.

Methods: We retrospectively examined the records of patients who underwent hip fracture surgery between 2013 and 2017. All patients had a baseline serum creatinine value and at least one later value. AKI was defined according to KDIGO guidelines.

Results: The study included 511 patients. Mean age was 72.6 years, 325 males (63.4%); 151 (29.5%) had baseline eGFR < 60 ml/min/1.73m². Of these, 87 (17%) developed AKI. Older age, diabetes mellitus, hypertension, and chronic heart condition were significantly more common in patients who developed AKI. Patients with AKI had increased 30-day mortality (hazard ratio [HR] 3.96, 95% confidence interval [95%CI] 1.62–9.7, P = 0.003) and mortality at one year (HR 2.72, 95%CI 1.5–4.9, P = 0.002). AKI was associated with surgery delay > 48 hours (HR 2.241, 95%CI 1.206–4.165, P = 0.011). Mean LOS was 10.9 days and 8 days for patients with AKI and without, respectively, P < 0.0001.

Conclusions: AKI is a common complication in patients with hip fracture and is associated with increased short- and long-term mortality, delayed surgery, and longer hospitalization. Interventions identifying and monitoring patients at risk may contribute to improve the outcomes

Background: Cystic periventricular leukomalacia (cPVL) is a strong indicator of subsequent motor and developmental impairments in premature infants. There is a paucity of publications on biomarkers of cPVL.

Objectives: To determine C-reactive protein (CRP) levels during the first week of life of preterm infants who later developed cPVL and to identify the association between CRP levels with perinatal factors.

Methods: We retrospectively included infants ≤ 32 weeks gestation and/or birth weights ≤ 1500 grams; 17 with a cranial ultrasound diagnosis of cPVL and 54 with normal ultrasounds. Serum CRP levels were measured during days 1-7 (CRP^1–7d) of life and subdivided into two timing groups: days 1–3 (CRP^1–3d) and days 4-7 (CRP^4–7d).

Results: The cPVL group had significantly higher mean CRP^4–7d levels compared to controls (12.75 ± 21.2 vs. 2.23 ± 3.1, respectively, P = 0.03), while CRP^1–3d levels were similar. CRP^1–7d levels were significantly correlated with maximal fraction of inspired oxygen during the first 12 hours of life (FiO₂-12h, r = 0.51, P < 0.001]. Additional risk factors were not associated with CRP levels.

Conclusions: Our finding of elevated CRP^4-7d levels and later development of cPVL supports earlier studies on the involvement of inflammation in the pathogenesis of cPVL. Whether CRP could serve as a biomarker of cPVL and its correlation with outcomes, awaits further trials. Furthermore, the correlation between FiO₂-12h and CRP^1–7d levels suggest that hypoxia and/or hyperoxia may serve as a trigger in the activation of inflammation during the first days of life of preterm infants

Background: Extra peritoneal packing (EPP) is a quick and highly effective method to control pelvic hemorrhage.

Objectives: To determine whether EPP can be as safely and efficiently performed in the emergency department (ED) as in the operating room (OR).

Methods: Retrospective study of 29 patients who underwent EPP in the ED or OR in two trauma centers in Israel 2008–2018.

Results: Our study included 29 patients, 13 in the ED-EPP group and 16 in the OR-EPP group. The mean injury severity score (ISS) was 34.9 ± 11.8. Following EPP, hemodynamic stability was successfully achieved in 25 of 29 patients (86.2%). A raise in the mean arterial pressure (MAP) with a median of 25 mmHg (mean 30.0 ± 27.5, P < 0.001) was documented. All patients who did not achieve hemodynamic stability after EPP had multiple sources of bleeding or fatal head injury and eventually succumbed. Patients who underwent EPP in the ED showed higher change in MAP (P = 0.0458). The overall mortality rate was 27.5% (8/29) with no difference between the OR and ED-EPP. No differences were found between ED and OR-EPP in the amount of transfused blood products, surgical site infections, and length of stay in the hospital. However, patients who underwent ED-EPP were more prone to develop deep vein thrombosis (DVT): 50% (5/10) vs. 9% (1/11) in ED and OR-EPP groups respectively (P = 0.038).

Conclusions: EPP is equally effective when performed in the ED or OR with similar surgical site infection rates but higher incidence of DVT

Background: Radical cystectomy is a complicated surgery with significant risks. Complications of Clavien–Dindo grade 3–4 range from 25% to 40% while risk of mortality is 2%. Pelvic surgery or radiotherapy prior to radical cystectomy increases the challenges of this surgery.

Objectives: To assess whether radical cystectomy performed in patients with prior history of pelvic surgery or radiation was associated with increased frequency of Clavien–Dindo grade 3 or higher complications compared to patients without prior pelvic intervention.

Methods: We retrospectively evaluated all patients who underwent radical cystectomy at our center over a 7-year period. All patients with pelvic radiation or surgery prior to radical cystectomy comprised group 1, while group 2 included the remaining patients.

Results: In our study, 65 patients required radical cystectomy at our institution during the study period. Group 1 was comprised of 17 patients and group 2 included 48 patients. Four patients from group 2 received orthotopic neobladder, while an ileal conduit procedure was performed in the remaining patients. Estimated blood loss and the amount of blood transfusions given was the only variable found to be statistically different between the two groups. One patient from group 1 had four pelvic interventions prior to surgery, and her cystectomy was aborted.

Conclusions: Radical cystectomy may be safely performed in patients with a history of pelvic radiotherapy or surgery, with complication rates similar to those of non-irradiated or operated pelvises.

Background: Limited data exist regarding the safety of ultrasound-guided femoral nerve blockade (US-FNB) in patients with hip fractures treated with anti-Xa direct oral anticoagulants (DOAC).

Objectives: To compare the safety outcomes of US-FNB to conventional analgesia in patients with hip fractures treated with anti-Xa DOAC.

Methods: This observational exploratory prospective study included 69 patients who presented to our emergency department (ED) in 3 years with hip fracture and who were treated with apixaban or rivaroxaban. Patients received either a US-FNB (n=19) or conventional analgesics (n=50) based on their preference and, and the presence of a trained ED physician qualified in performing US-FNB. Patients were observed for major bleeding events during and 30 days after hospitalization. The degree of preoperative pain and opioid use were also observed.

Results: We found no significant difference in the number of major bleeding events between groups (47.4% vs. 54.0%, P = 0.84). Degree of pain measured 3 and 12 hours after presentation was found to be lower in the US-FNB group (median visual analog scale of pain improvement from baseline of -5 vs. -3 (P = 0.002) and -5 vs.-4 (P = 0.023), respectively. Opioid administration pre-surgery was found to be more than three times more common in the conventional analgesia group (26.3% vs.80%, P < 0.0001).

Conclusions: Regarding patients treated with Anti-Xa DOAC, US-FNB was not associated with an increase in major bleeding events compared to conventional analgesia, although it was an effective means of pain alleviation. Larger scale randomized controlled trials are required to determine long-term safety and efficacy.

Background: Hip fractures in elderly patients are a major cause of morbidity and mortality. Variability in length of hospital stay (LOS) was evident in this population. The coronavirus disease-2019 (COVID-19) pandemic led to prompt discharge of effected patients in order to reduce contagion risk. LOS and discharge destination in COVID-19 negative patients has not been studied.

Objectives: To evaluate the LOS and discharge destination during the COVID-19 outbreak and compare it with a similar cohort in preceding years.

Methods: A retrospective study was conducted comparing a total of 182 consecutive fragility hip fracture patients operated on during the first COVID-19 outbreak to patients operated on in 2 preceding years. Data regarding demographic, co-morbidities, surgical management, hospitalization, as well as surgical and medical complications were retrieved from electronic charts.

Results: During the pandemic 67 fragility hip fracture patients were admitted (COVID group); 55 and 60 patients were admitted during the same time periods in 2017 and 2018, respectively (control groups). All groups were of similar age and gender. Patients in the COVID group had significantly shorter LOS (7.2 ± 3.3 vs. 8.9 ± 4.9 days, P = 0.008) and waiting time for a rehabilitation facility (7.2 ± 3.1 vs. 9.3 ± 4.9 days, P = 0.003), but greater prevalence of delirium (17.9% vs. 7% of patients, P = 0.028). In hospital mortality did not differ among groups.

Conclusions: LOS and time to rehabilitation were significantly shorter in the COVID group. Delirium was more common in this group, possibly due to negative effects of social distancing.