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Introduction: Recently, a Geriatric Surgery Unit (GSU) was established in the Sheba Medical Center. The Unit's aims include: professional assessment of surgical candidates, approval of the surgical plan by a multidisciplinary team discussion (MTD), and meeting the specific needs of the geriatric patient undergoing surgery., Methods: We describe the establishment of the GSU and preliminary results from the first year of its activity (January-December 2022). The GSU team consisted of a geriatric nurse practitioner (NP), a geriatric physician, surgeons, anesthesiologists and a physiotherapist. Inclusion criteria for GSU assessment/treatment were age>80 years or substantial baseline geriatric morbidity., Results: In 2022, 276 patients were treated by the GSU: 110 underwent elective comprehensive preoperative assessment in the NP clinic and the rest were assessed urgently/semi-electively during their hospitalization. One hundred and fifteen cases (median age 86 (65-98) years) were brought to MTD and considered for elective cholecystectomy (46.1%), colorectal procedures (16.5%), hernia repair (13.9%), hepatobiliary procedures (9.6%) or other surgeries (13.9%); of those, 49 patients (median age 86 (72-98) years) eventually proceeded to surgery, following which the median length of hospital stay (LOS) was 3.5 (1-60) days and the rate of postoperative complications was 46.7%. After discharge, the median duration of follow-up was 2.5 (0-18) months during which 4 patients died. Compared with geriatric patients who underwent cholecystectomy during 2021-2023 without MTD (n=39), in the cases discussed by the MTD, patients (n=17) had a shorter LOS (2.0±0.9 vs. 2.4±2.1 days), less 30-day Emergency Department referrals (12.5% vs. 28.2%) and less 30-day re-admissions (6.2% vs. 15.4%; all p≥0.3)., Conclusions: Geriatric surgical patients require a designated professional approach to meet their unique perioperative needs. The effect of GSUs on perioperative outcomes merits further prospective studies.

Introduction: The therapeutic approach to diverticular disease has changed significantly in recent decades. From a disease treated almost exclusively by surgery, diverticulitis is nowadays treated operatively in specific indications, shifting the majority of patients towards an outpatient based treatment. Significant changes occurred not only in uncomplicated diverticular disease but also in complicated cases, treated in the past with emergency surgery. These changes have been studied relentlessly around the world, and despite the fact that the vast majority of patients presenting with acute diverticular disease are not treated with surgery, it is still considered a surgical condition. In this review article, we set out to examine whether there is still justification to consider acute diverticulitis as a surgical disease and in addition, to examine whether the changes in treatment seen around the world are compatible with the current treatment strategies implemented in Israel.

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.

Aims: The purpose of this study was to portray and analyze the inter-relationship between the use of HRT, mammographic breast density and the finding of any mammographic abnormality that prompted further investigation such as core needle biopsy or additional imaging testing, while controlling for obstetric and relevant demographic data., Background: Mammographic breast density has been associated with higher risk of breast cancer and decrease in its sensitivity, while hormonal replacement therapy (HRT) in turn, has been implicated in increasing mammographic density and is considered a risk factor for breast cancer by itself. The inter-relationship between HRT, breast density and any mammographic or sonographic finding requiring further investigation has not been fully investigated., Methods: A total of 2,758 consecutive, screening mammograms performed during one year in a single academic medical center in Israel were analyzed. Each mammogram was supplemented by high resolution ultrasound. Density was measured by a visual, semi-quantitative, 5-grade scale, based on Boyd's classification and grouped into low density mammograms (LDM) (1-3) and high density mammograms (HDM) (4-5). Demographic and obstetric data, personal and family history of breast cancer, and the use of HRT were entered into the database. These parameters were correlated with breast density and any detected abnormality that prompted further investigation. Univariate and multivariate analyses as well as multivariate logistic regression were performed using SAS 9.2., Results: A significant difference in density was observed between pre- and post-menopausal women (p = 0.0001). However, the use of HRT in post-menopausal women was not associated with higher incidence of HDM (18.6%, n=110/592) compared to post-menopausal women without HRT (15.4%, n=211/1370) (p=n.s). Mammographic abnormality was more likely to occur in post-menopausal women without HRT (52%, n=711/1370) compared with women on HRT (38.7% n=229/592) (p = 0.0001). This held true for solid lump (p=0.0001), tissue irregularity (p=0.016) and calcifications (p=0.0005). Menopause was associated with higher likelihood (48%) of any mammographic finding compared with 41.6% in pre-menopausal women (p = 0.0017). A total of 266 women with mammographic findings prompting histological assessment were identified, revealing 105 malignant lesions. HRT in post-menopausal women was associated with lower incidence (28%) of malignancy compared to post-menopausal women without HRT (50%)., Conclusions: The present study, portraying the inter-relationship between mammographic breast density, any abnormal finding in screening mammograms, and the use of HRT has not found such treatment to be associated neither with increased density, nor with higher probability of finding malignancy. Furthermore, a lower incidence of mammographic abnormality was noted in HRT users. Albeit, further and larger studies are required to substantiate these findings. The results of this study do not support the notion that HRT increases the likelihood of malignancy or affects breast density.

Background: In recent years the city of Eilat has come under threat of rocket attacks. This emphasized the need for an upgrade of the city's medical center capabilities in trauma care. Medical simulation has been used for many years in training and for the improvement of trauma care both at the field Level and in hospitals. Although there was significant improvement in the technological aspects of simulations, the use of simulators was restricted mainly to simulation centers and its effectiveness in training and assessment of trauma teams in situ in emergency departments was still not examined., Objectives: To train the personnel engaged in trauma care in a small rural medical center in the fastest and most comprehensive manner, using a mobile and highly sophisticated medical simulator., Methods: A team of simulation specialists from MSR, Israel Center for Medical Simulation, held a one week long course including all the staff members involved in trauma care, 38 doctors and nurses in total. All drills were recorded and then reviewed in the debriefing. Four staff members were trained in video debriefing at MSR. The participants were requested to complete questionnaires before and after training., Results: Subjective feelings of competence in the team's ability to treat trauma patients were found to improve after training. Airway management rating of very good improved from 21.05% prior to training to 50% after the course. Chest trauma management and hemorrhage control scores of very good rose from 10.53% and 26.32% before to 42.11% and 55.26% respectively after the course. The highest improvement was measured in teamwork performance, which was ranked as very good: 10.53% before training and elevated to 47.37% after training. A total of 74% of the responders stated that this training program contributed very significantly to their trauma care capabilities., Conclusions: The use of mobile medical simulations combined with instructors from within the hospital enabled the training and assessment of the trauma care in situ and in a short time.

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.

Introduction: Progress has been made in the treatment of metastatic colorectal cancer with the development of biologic agents such as Cetuximab and Panitumumab. These monoclonal antibodies are directed against EGFR and influence cell division, attachment, angiogenesis, migration and apoptosis. Correlation has been found between the presence of mutations in the K-ras gene and resistance to treatment with Cetuximab.New guidelines require K-ras mutation analysis before anti-EGFR treatment is provided. The proteins Amphiregulin and Epiregulin belong to the Epidermal growth factors family (EGF, that act through the EGFR. Over-expression of these proteins has been seen in a variety of malignancies and non-malignant pathologies. These proteins can be detected in samples from colorectal malignancies and inflammatory bowel disease by immunohistochemical staining. Jacobs et at showed that mRNA expression of these proteins n colorectal malignancy predicts outcomes in wild type K-ras metastatic patients treated with Cetuximab., Aim: The purpose of our study is to examine whether there is a correlation between the presence of colorectal cancer K-ras mutations and the level of expression of EpireguLin and Amphiregulin in the malignant tissue., Material and Methods: In a retrospective study we examined 30 tissue samples of colon cancer patients for the presence of K-ras mutation and immunohistochemicaL staining for Epiregulin and AmphireguLin., Results: A total of 14 (46.66%] samples showed mutation in the K-ras gene; 15 of 30 samples [50%] were positive for AmphireguLin. As for Epiregulin, 10 (33.3%) samples had strong staining, 10 (33.3%) samples had Light staining and the rest, 10 (33.3%) didn't have any staining. In conclusion, we did not find a correlation between the presence of a K-ras mutation and the presence of Epiregulin and Amphiregulin in colon cancer tissue.

Cancer cachexia is mediated by cytokines affecting intermediate metabolism of energy, proteins, carbohydrate and lipid. It is aggravated by common therapeutic measures: surgery, chemotherapy and radiotherapy that reduce oral intake as well as increase catabolism. Enteral or parenteral nutrition support decreases the catabolic rate of the patient, helping the patient withstand the side effects of the therapeutic measures, but do not reverse to anabolism. Terminally ill cancer patients who are refractory to the different therapeutic measures need palliative care. Nutrition is a basic human right and is conceived by the patient and his family, as well as by the medical community and human society, to be vital for survival. We obviously make every effort to feed our cancer patients as long as they can tolerate food via the alimentary system. However, we are reluctant to administer parenteral feeding, due to fear of accelerated tumor growth, complications, cost and futility, thereby leading to unnecessary prolongation of suffering. However, there is a group of patients who, although they are not candidates for any antineoplastic therapy, are still in good physical and mental condition, with expected life spans of three months or more, suffering from conditions such as intestinal obstruction, fistulas or any condition which makes the preferred route of enteral nutrition impossible. In these specific patients, palliative parenteral nutrition should be considered. The functional status of the patient has to be reasonable (Karnofsky status > 50, ECOG< 3). The decision should be taken after careful multidisciplinary discussion. The patient and caregivers should be aware that this is not a cancer-specific treatment and probably will not prolong the patient's life. Total parenteral nutrition (TPN) in this situation is best if provided at the patient's home.

Paget's disease of the breast is a rare malignancy of the nipple-areola complex, comprising 0.5-4% of all breast cancers which is often associated with an underlying in-situ or invasive carcinoma in the breast parenchyma. It is manifested by progressive eczematoid changes of the areola with persistent soreness or itching. Due to the seemingly benign appearance, diagnosis is often delayed by more than six months. There are two main theories regarding the histogenesis of the disease: the epidermotropic and the in-situ transformation. The first suggests that Paget cells are ductal cells that have migrated from an underlying carcinoma of the breast parenchyma to the epidermis of the nipple. The second postulates that nipple keratinocytes undergo transformation into malignant cells independent from any pathology within the breast parenchyma. Prognosis is determined by the nature of the concurrent tumor in the breast. In 50% of cases a palpable mass is evident and it usually represents an infiltrating carcinoma with involved axillary lymph nodes. In the absence of a mass the prognosis is invariably better as it usually reflects a noninvasive tumor (DCIS). The standard treatment has been mastectomy. However in an era when breast conserving surgery is implemented even for advanced infiltrating breast tumors, there might be a role for such a treatment for selected patients with Paget's disease.

Soft tissue sarcomas are exceedingly rare, making up less than 1% of all solid malignancies. In the retroperitoneum, they tend to be large when diagnosed and are a therapeutic challenge to the surgical oncologist. Our experience with 51 patients with retroperitoneal sarcomas operated on during the past 4 years is presented. 37 were primary and 26 presented as recurrent tumors. The group included many different histological subtypes, the majority being high grade tumors. Complete resection was achieved in 84%, necessitating extensive surgery, but was not possible in 8 patients (16%) who underwent partial resection or biopsy only. There was 1 perioperative fatality (2%). 18 (35%) suffered complications, all of which were reversible. The estimated 5-year survival in the complete resection group is 40%, while none of those who underwent partial resection survived more than 2 years. There was significantly better survival in patients with primary, low grade sarcomas which were smaller than 8 cm, compared to those with high-grade, recurrent sarcomas larger than 8 cm. Local recurrence developed in 8 patients of the complete resection group (18%), 2 months to 3 years after surgery. These data show that despite the concept of retroperitoneal sarcomas as being aggressive, invasive tumors with a poor prognosis, the prognosis is not unusually bad. With proper surgical technique, resectability may be high, with improved overall survival.

Tumor necrosis factor (TNF) induces rapid necrosis in a variety of experimental neoplasms. However, its clinical application is limited by life-threatening systemic toxicity. Isolated limb perfusion (ILP) enables administration of large doses of TNF and cytotoxic drugs directly to the affected limb, avoiding systemic toxicity. We describe our experience in 20 consecutive patients (10 with melanoma and 10 with soft tissue sarcoma) treated with high-dose TNF and melphalan via ILP. ILP was performed via the external iliac (10 cases), femoral (2), popliteal (5) or brachial (3) vessels. Patients received 3-4 mg TNF to an upper, and 1-1.5 mg/kg to a lower extremity. Isolation efficiency was determined by injection of radiolabelled albumin. The procedure was successful in all 20 patients. Local complications included wound infection in 6 cases and hematoma in 2. 1 patient developed sepsis secondary to extensive necrosis of a large, secondarily infected tumor. The first 6 patients who underwent high-flow perfusion experienced systemic side-effects, mainly hypotension. These side-effects were eliminated when low-flow perfusion was introduced. The response rate was 100%. In the sarcoma group, 5/10 had complete response, and 5 partial response. Amputation or mutilating surgery was avoided in 9/10. Of the 10 with melanoma, 7 had complete, and 3 partial response. We conclude that administration of TNF via ILP is a safe and effective modality for treating advanced neoplasms of the limbs.

The protooncogene HER2/neu was analyzed in 27 women with invasive breast cancer and in 26 with benign breast conditions. Gene amplification was found in 3 patients, 1 in stage 3 and 2 in stage 4. In 3 patients in stage 2 overexpression of protein was found. Although amplification of the gene was found to be a significant predictor of clinical outcome (p < 0.05), high expression of the gene did not correlate with prognosis. In women with benign breast conditions there were no alterations of HER2/neu amplification may become a molecular marker in some malignancies. It should be noted that since few tumors show amplification, examination of a small series may not reveal clinical association with these alterations. Therefore, our conclusions require confirmation on a larger scale with long-term clinical follow-up.

In chemofiltration a large dose of a cytotoxic drug is infused into an artery supplying a cancerous area, thus limiting systemic toxicity. The venous return from the area is pumped into a chemofiltration unit at 750 ml/min and the drug is filtered out of the blood, which is then returned to the systemic circulation. Of 22 patients with locally advanced cancer, systemic chemotherapy had failed in 63%. 9 of them underwent chemofiltration of the liver for advanced metastatic cancer of the colon (4 cases), rectum (2), breast (2) and ovaries (1); and 13 underwent chemofiltration of the pelvis for advanced cancer of the rectum (5), malignant melanoma (5), ovaries (1), cervix uteri (1) and vulva (1). The following drugs were used: 5-FU (750 mg/m2/10 min) and mitomycin-C (30 mg/m2/10 min) for colorectal, ovarian and breast carcinomas; melphelan (1 mg/kg/20 min) or cisplatinum (200 mg/m2/30 min) for malignant melanoma or ovarian carcinoma; mitomycin-C or bleomycin (50 mg/m2/10 min) for carcinoma of the cervix or vulva. 1 patient with extensive liver metastases died of respiratory failure 28 days after the procedure. Surgically related complications occurred in 16% and included wound hematoma (2 cases), infection (1) and venous thrombosis (1). Drug-related complications occurred in 50%, and included transient leukopenia (9), mild renal failure (1), hair loss (2) and prolonged paralytic ileus (1). Partial remission was observed in 10/20 patients who had measurable disease. Time to progression was 5.4 months (range: 4 weeks to 20 months). Stabilization of disease occurred in 7/20 (35%), while in 3 the disease progressed.(ABSTRACT TRUNCATED AT 250 WORDS)