Ian White

Tel Aviv University, Tell Afif, Tel Aviv, Israel

Are you Ian White?

Claim your profile

Publications (14)33.45 Total impact

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Clinical data and animal models support an association between postoperative inflammatory response and the risk of colorectal cancer recurrence. Our aim was to evaluate postoperative peritoneal inflammation and its impact on cultured colon cancer cells’ migration capacity. Methods. 23 patients undergoing elective colorectal resection with uneventful recovery were prospectively enrolled. Patients were operated on for both malignant and benign etiologies. Peritoneal fluids collected at surgery initiation and after surgery were evaluated for their effect on migration potential of human colon cancer cells using an in vitro scratch assay and on TNF- α , IL-1 β , IL-6, and IL-10 levels using bead-based fluorokine-linked multianalyte profiling. Results. Postoperative peritoneal fluid from all patients increased the migration capacity of colon cancer cells compared to preoperative levels. This effect was significant during the first two postoperative days and decreased thereafter. The increase in colon cancer cell migration capacity correlated with increased levels of peritoneal TNF- α and IL-10. Conclusion. In this pilot study, we have demonstrated that the intraperitoneal environment following colorectal resection significantly enhances colon cancer cells migration capacity. This effect is associated with postoperative intra-abdominal cytokines level. A larger scale study in colorectal cancer patients is needed in order to correlate these findings with perioperative parameters and clinical outcome.
    Full-text · Article · Jan 2016 · Gastroenterology Research and Practice
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Numerous factors have been associated with the number of lymph nodes retrieved during laparoscopic colectomy. This study compared the impact of vascular pedicle ligation method on the number of retrieved lymph nodes in patients undergoing laparoscopic right hemicolectomy for cancer. Mesenteric root dissection with individualized vessel ligation was compared to en bloc vascular root stapling. Methods: Data were retrospectively collected from a database of patients' charts including operative and pathological reports. All patients that underwent laparoscopic colectomy in a single department were identified. Patients that underwent elective laparoscopic right hemicolectomy for cancer were further evaluated. The impact of the method used for ileo-colic vascular transection, age, gender, nodes status, T stage, BMI and the operating surgeon on the number of retrieved lymph nodes was studied. Results: Among 239 laparoscopic colectomies, 75 patients underwent elective laparoscopic right colectomy for cancer. Ileo-colic vascular transection was routinely performed at the level of the inferior border of the pancreas. In total, 34 patients underwent ileo-colic vascular root dissection with individualized vessel ligation and 41 underwent vascular root stapling. No difference was found in the mean number of retrieved lymph nodes between pedicle dissection and vascular root stapling (18.7 ± 5.9 vs. 19.6 ± 7.9, P = 0.396), and in the rate of patients who had 12 nodes or more (97.1 vs. 92.7 %, P = 0.401). BMI above 30 was associated with decreased number of retrieved nodes (P = 0.001). Conclusions: No difference was found in the number of retrieved lymph nodes between ileo-colic vascular root dissection with individual vessel ligation and vascular root stapling in patients undergoing laparoscopic right hemicolectomy for cancer. High BMI was associated with decreased number of retrieved nodes in both groups. A standard approach regarding the level of mesenteric root transection, regardless of the ligation approach, leads to adequate lymph node harvesting by different surgeons.
    No preview · Article · Oct 2015 · Surgical Endoscopy
  • R Ghinea · I White · B Benjamin · D Kidron · B Shpitz · S Avital
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Extralevator abdominoperineal resection (ELAPR) for low rectal cancers has shown superior oncological results compared with conventional abdominoperineal resection (APR) with less circumferential margin (CRM) involvement, less intraoperative bowel perforation and a lower local recurrence rate [1].There is currently no standardized technique for ELAPR. Different related aspects such as the use of laparoscopy, the extent of pelvic dissection, the method of pelvic floor reconstruction or the application of a parastomal prophylactic mesh may be considered.Laparoscopic dissection may consist of limited pelvic dissection [2] or more extensive dissection including laparoscopic transabdominal levator transection [3].Closure of the large perineal defect is challenging and may be approached by several methods [4], and the high risk of a future parastomal hernia may justify the use of a prophylactic parastomal mesh [5].We present here our laparoscopic-assisted ELAPR approach. Our fin ...
    No preview · Article · Feb 2015 · Techniques in Coloproctology
  • [Show abstract] [Hide abstract]
    ABSTRACT: Allogeneic perioperative blood transfusion (PBT) has been associated with higher rates of postoperative complications in patients undergoing colorectal surgery and increased tumor recurrence in cancer patients. Our aim is to evaluate possible predictive factors for PBT, specifically, in patients undergoing laparoscopic colorectal surgery, in order to identify patients who could benefit from alternatives to allogenic PBT such as erythropoietin administration, autologous blood transfusion, and possibly preoperative blood transfusion. Five hundred patients who underwent laparoscopic colorectal surgery between the years 2003 and 2011 were reviewed. Patient demographics and clinicopathologic variables were collected prospectively. Other clinical data were collected directly from the computerized records of the in-hospital blood bank. PBT was defined as transfusion of allogenic red blood cells during the day of operation or within the postoperative hospitalization. The associations between PBT and patient variables were assessed by univariate and multivariate analyses. Of the 500 patients, 134 patients (26.8 %) received PBT. Multivariate analysis revealed four preoperative variables as significant risk factors for PBT: preoperative hemoglobin (P = 0.001), lower rectal surgery (P = 0.009), Charlson comorbidity score (P = 0.001), and malignancy (P = 0.024). Preoperative Charlson score, hemoglobin level, carcinoma, and lower rectum pathologies were found to be independent risk factors for PBT in patients undergoing laparoscopic colorectal surgery. Evaluation of these risk factors prior to surgery may be helpful in selecting the patients who could benefit from possible alternatives to perioperative allogeneic blood transfusion and help constitute guidelines for a more responsible use of these alternatives.
    No preview · Article · Apr 2014 · International Journal of Colorectal Disease
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Laparoscopic surgery has been associated with a perioperative decrease in renal function. As a result, an open approach may be preferred in patients with impaired renal function when prolonged laparoscopic procedures are anticipated. The aim of this study was to examine changes in renal function following colorectal operations and compare between the open and the laparoscopic approaches, in patients with preoperative impaired renal function. Patients and methods: This is a single-center retrospective study. Records of all patients with impaired renal function (estimated glomerular filtration rate [eGFR] <60 mL/minute) who underwent elective colorectal resection between 2007 and 2011 were reviewed. The changes in eGFR were examined and compared between open and laparoscopic procedures. Results: Ninety consecutive patients with impaired renal function who underwent elective colorectal surgery from 2007 to 2011 were identified. Forty-seven patients underwent laparoscopic surgery, and 43 had an open surgery; 23.2% of the patients who had open surgery and 21.7% of the patients who underwent a laparoscopic procedure demonstrated a decrease in eGFR at the time of discharge (P=not significant). The mean decrease in eGFR did not differ between the two groups (6.3 ± 6.8 mL/minute versus 4.04 ± 4.01 mL/minute; P=.34). None of the patients required dialysis. Postoperative complications were found to be a risk factor for a significant decrease in renal function. Conclusions: Renal function may deteriorate in patients with chronic kidney disease who undergo elective colorectal surgery. No difference was noted in the incidence or severity of such deterioration between open and laparoscopic approaches. Postoperative complications are associated with deterioration in renal function regardless of the operative approach.
    No preview · Article · Feb 2014 · Journal of Laparoendoscopic & Advanced Surgical Techniques
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Perioperative blood transfusion has been associated with a poor prognosis in patients undergoing surgery for colorectal cancer. The aim of this study was to evaluate risk factors for blood transfusion and its impact on long-term outcome exclusively in patients undergoing laparoscopic surgery for curable colorectal cancer. Methods: Data were retrieved from a prospectively collected database of patients who underwent laparoscopic surgery for curable colorectal cancer over a 6-year period. Long-term data were collected from our outpatient clinic and personal contact when necessary. Results: Two hundred and one patients underwent laparoscopic surgery for curable colorectal cancer (stage I-III). Sixty-eight (33.8 %) received blood transfusions during or after surgery. These patients were typically older, had lower preoperative hemoglobin levels, had a more advanced cancer, had a higher Charlson score, had a higher rate of complications and had a higher conversion rate. Kaplan-Meier overall survival analysis was significantly worse in patients who received blood transfusions (P = 0.004). Decreased disease-free survival was also observed in transfused patients; however, this did not reach statistical significance (P = 0.21). A multivariate analysis revealed that transfusion was not an independent risk factor for decreased overall and disease-free survival. The Charlson score was the only independent risk factor for overall survival (OR = 2.1, P = 0.002). Independent factors affecting disease-free survival were stage of disease, Charlson score and, to a lesser degree, age and body mass index. Conclusions: Perioperative blood transfusion is associated with decreased long-term survival in patients undergoing laparoscopic resection for colorectal cancer. However, this association apparently reflects the poorer medical condition of patients requiring surgery and not a causative relationship.
    No preview · Article · Apr 2013 · Techniques in Coloproctology
  • [Show abstract] [Hide abstract]
    ABSTRACT: Morphine for postoperative pain control is commonly titrated via intravenous patient-controlled analgesia (IV-PCA). An IV morphine background infusion is rarely used. We investigated whether analgesia is effectively attained and morphine consumption is reduced if PCA titration is coadjuvated by a continuous infusion protocol. Following colorectal cancer surgery, consenting patients were randomized to receive a minimal ("sub-analgesic") dose of morphine 0.01 mg/kg/h background infusion plus a 0.01 mg/kg bolus (BI), or a 1.5mg bolus-only morphine (B0) (bolus ratio ∼1:2). Bolus lockout time was 7 min in either case. All patients received 0.1mg/kg morphine before protocol initiation, and diclofenac 75 mg intramuscularly b.i.d. during the study period, lasting 48 h. Eighty-six patients (51 males, age 26-95 years) participated in the study. The total mean morphine consumption during the 48 h was 25% lower in the BI than in the B0 group (P<0.05). Although the former applied the PCA device for boluses 19% less than the latter (P<0.05), their pain score was lower (P<0.05) most of the time, and they reported greater satisfaction (P<0.05) on a 10-scale numerical rating score. Pre- and postoperative vital signs were similar for both groups. No patient depicted hypoxemia or lapsed into deep sedation. Four BI and three B0 patients required treatment for postoperative nausea and vomiting. One BI patient had transient pruritus and one B0 69-year individual became disoriented 24h into treatment; either event subsided soon after stopping their respective regimen without the need for treatment. The main conclusions of the results are that very-low-dose background morphine infusion combined with small-dose PCA boluses may provide better pain relief, lower morphine consumption, and minimal complication rate as a 1.5mg PCA bolus-only protocol.
    No preview · Article · Apr 2012 · Pharmacological Research
  • I White · S Avital · R Greenberg
    [Show abstract] [Hide abstract]
    ABSTRACT: Stapled haemorrhoidopexy (SH) is associated with minor postoperative pain and high overall satisfaction rates. Some patients will have persistent or recurrent symptoms requiring re-intervention. All patients who underwent SH for grade III internal haemorrhoids and required a second SH (2005-2008) were studied. Grade IV patients were excluded. Data on surgical technique, postoperative pain, complications, time to first bowel movement, functional recovery and suspected reason for first SH failure were retrieved from medical records. Similar data were collected for the second procedure at four postoperative follow-up visits. Twelve patients were enrolled. The mean time to recurrent symptoms was 15 months. The indications for repeated surgery were bleeding, prolapse, and pruritus w/wo discharge. Recurrence was attributed to a too high staple line in the first procedure (n = 4) and an incomplete resected ring (n = 1). The median operative time of the second procedure was 24 min (17-29) and the median follow up was 20 ± 4.3 months (15-30). Repeat SH was associated with higher pain scores, more analgesic requirements, and longer recovery period compared to the first procedure. There were no early or late postoperative complications. Histological examination of the 12 tissue doughnuts resected during the second SH showed no smooth muscle fibres in any of the patients. After 12 months of follow up, 10 patients with repeated SH remained asymptomatic, while 2 had recurrent bleeding. Repeat SH can be performed safely and reliably without risk of complications, but the second SH is associated with more pain and longer recovery time.
    No preview · Article · Sep 2011 · Colorectal Disease
  • [Show abstract] [Hide abstract]
    ABSTRACT: Ketamine induces a short-term effect on postoperative pain when administered intravenously immediately before or during acute pain. Repeated administration of low-dose ketamine may induce long-term pain relief in chronic pain syndromes. The aim of our study was to determine whether ketamine's effect on acute postoperative pain could be enhanced and prolonged and analgesia consumption reduced if it was administered intramuscularly in repeated and escalating subanesthetic doses many hours before surgery. Patients who were scheduled for tumor resection under general anesthesia were randomly and blindly given preoperative IM ketamine (K) or normal saline (placebo [P]) following 1 of 3 consecutive protocols (2 groups/protocol, 20 patients/group): 1 dose (25-mg ketamine or 1-mL saline) at 4 hours preoperatively (K1 or P1); 2 doses (10- and 25-mg ketamine or 1-mL saline twice) at 11 and 4 hours (K2 or P2); or 3 doses (5-, 10-, and 25-mg ketamine or 1-mL saline thrice) at 17, 11, and 4 hours preoperatively (K3 or P3). No other preoperative medications were given. Postoperatively, all patients received morphine (1.5 mg/bolus) via an intravenous patient-controlled analgesia (PCA) device. A total of 120 patients took part in the study. Patients' ages ranged from 15 to 75 years; mean weight (76 [14] kg; range, 50-120), gender (69 men, 51 women), and race were equally distributed among the groups. There were no significant differences in intraoperative parameters among the groups. The patients' mean self-rated 48-hour pain scores on a numerical rating scale were lower in the K2 and K3 groups than in their corresponding placebo groups (K2: 1.67 [1.04] vs P2: 3.62 [1.93] [P = 0.0004]; K3: 2.22 [1.37] vs P3: 3.25 [1.76] [P = 0.046]). These groups also used ∼35% less morphine compared with the placebo groups (K2: 28.4 [20.4] mg, K3: 26.6 [16.0] mg vs P2: 42.4 [30.4] mg, P3: 40.9 [21.2] mg [P ≤ 0.02]). Intravenous PCA usage among K2 and K3 patients was ∼50% less than the usage among their placebo counterparts (P < 0.05). The 1-ketamine-injection patients' pain scores and analgesic consumption were similar to those of their placebo groups. The 25-mg-ketamine injections caused dizziness that lasted up to 2 minutes. Our 48-hour data suggest that 2 or 3 escalating subanesthetic doses of IM ketamine injected consecutively hours before surgery attenuated postoperative pain and reduced morphine consumption in these subjects.
    No preview · Article · Jun 2011 · Clinical Therapeutics
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Long-term outcome of patients following conversion during laparoscopic surgery for colorectal cancer is not often reported. Recent data suggest a negative impact of conversion on long-term survival. This study aimed to evaluate the impact of conversion on the perioperative outcome and on long-term survival in patients who underwent laparoscopic resection for curable colorectal cancer. Evaluation of our prospective in-hospital collected data of patients who underwent laparoscopic surgery for curable colorectal cancer over a 5-year period. Long-term data were collected from our outpatient's clinic data and personal contact when necessary. During the study period, 175 patients were operated on laparoscopically for curable colon cancer (stage I-III). Mean follow-up was 33±18 months with a minimum follow-up of 12 months. For various reasons, 25 patients (14.4%) had to be converted to open surgery. Short-term outcome revealed a trend towards longer operations, a higher rate of surgical complications, and a longer hospital stay in the converted group. Five-year, Kaplan-Meier, disease-free analysis was worse for converted patients. Overall survival did not differ between the 2 groups. Cox proportional hazards regression analysis revealed that conversion and AJCC stage were independent risk factors for recurrence. Conversion in laparoscopic surgery for curable colorectal cancer is associated with a worse perioperative outcome and worse disease-free survival.
    Full-text · Article · Apr 2011 · JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Neuraxial administration of morphine is an effective way of controlling postoperative pain and reducing analgesic consumption. Some animal models have demonstrated that preemptive administration of neuraxial narcotics reduces pain, while others have revealed the contrary. In addition, there have been no consistent results in clinical settings. This double-blind, randomized study compared the effects of pre- vs. post-incisional administration of neuraxial morphine on postoperative pain perception and analgesic requirements over 48 hours following laparotomy for open colectomy under standardized general anesthesia. Twenty patients received epidural morphine (3 mg) before the incision and saline after wound closure (MO1 group), and twenty patients received epidural saline before the incision and morphine after wound closure (MO2 group). Postoperatively, all patients received morphine boluses (1.5 mg) via intravenous patient-controlled analgesia (IV-PCA) and rescue doses of intramuscular diclofenac (75 mg) every 6 hours, as needed. MO1 patients used significantly (P<0.05) more morphine than the MO2 group during the first 24 postoperative hours and activated the PCA device more frequently throughout the 48-hour study period. The MO1 group was characterized by significantly (P<0.05) higher self-rated pain scores than the MO2 group throughout the study. The self-rated levels of sedation and satisfaction of the MO2 patients were also consistently better (P<0.05) than those of the MO1 patients, especially during the second postoperative day. Pre-incisional epidural morphine in patients undergoing open colonic surgery under general anesthesia was associated with more postoperative pain, a greater need for analgesics, and poorer patient satisfaction compared to post-incisional morphine administration.
    Full-text · Article · Apr 2011 · Minerva anestesiologica
  • [Show abstract] [Hide abstract]
    ABSTRACT: The number of retrieved lymph nodes in colorectal cancer resection may have an impact on staging and survival. Examination of at least 12 nodes has become a quality measure for adequate surgical practice. To evaluate the impact of the number of retrieved lymph nodes in laparoscopic colorectal surgery for cancer on node-negative patients' survival. Evaluation of our prospective in-hospital collected data of patients that underwent laparoscopic surgery for curable colorectal cancer over a 5-year period. Long-term data were collected from our outpatient's clinic data and personal contact when necessary. During a 5-year period since September 2003,173 patients were operated laparoscopically for curable colorectal cancer. Of the 117 patients who were node negative, 85 node-negative patients (72%) had 12 or more evaluated lymph nodes (mean, 18.3 + 2.4), while 32 node-negative patients had less than 12 (mean, 8.3 + 6.2). Patients with fewer than 12 nodes evaluated had significantly more left-sided tumors, while patients with 12 nodes or more had more right-sided tumors. A comparison of 5-year disease free and overall Kaplan-Meier survival curves revealed no statistically significant difference between the two groups. Evaluation of less than 12 nodes may not necessarily impact patients' survival in node-negative patients undergoing laparoscopic resection for curable colorectal cancer. A lower number of nodes may be sufficient.
    No preview · Article · Jun 2010 · Techniques in Coloproctology
  • [Show abstract] [Hide abstract]
    ABSTRACT: Intense pain in the first 12 hours after major abdominal surgery requires the use of large amounts of analgesics, mainly opioids, which may produce undesirable effects. Buprenorphine (BUP) is not typically used intravenously in this setting, particularly in combination with morphine (MO), due to concerns that BUP might inhibit the analgesic effect of MO. This study compared the analgesic effect of BUP and MO separately and in combination for postoperative pain control in patients undergoing abdominal surgery. In this double-blind study, adult patients were randomized to receive 1 of 4 regimens for 12 hours: a basal BUP infusion (BUP-i) of 0.4 microg/kg/h + BUP boluses (BUP-b) of 0.15 microg/kg each; a basal MO infusion (MO-i) of 10 microg/kg/h + MO boluses (MO-b) of 5 microg/kg each; a basal BUP-i of 0.4 microg/kg/h + MO-b of 5 microg/kg each; or a basal MO-i of 10 microg/kg/h + BUP-b of 0.15 microg/kg each. Bolus doses were delivered by intravenous patient-controlled anesthesia, with a bolus lockout time of 7 minutes. Diclofenac 75 mg IM q6h was available as rescue pain medication. Every 15 minutes during the first 2 postoperative hours and hourly thereafter, patients used visual analog scales to rate their pain (from 0 = totally free of pain to 10 = unbearable pain), level of sedation (from 1 = totally awake to 10 = heavily sedated), and satisfaction with treatment (from 1 = totally unsatisfied to 10 = fully satisfied). Blood pressure, heart rate, respiration rate, and arterial blood oxygen saturation (SpO(2)) were monitored, and adverse effects reported by patients or noted by clinicians were recorded at the same times. Study end points included total opioid consumption (infusion + boluses), demand:delivery ratio, and use of rescue medication. One hundred twenty patients (63 men, 57 women; age range, 21-80 years; weight range, 40-120 kg) were included in the study. Seventy-four percent had other mild, treated diseases (American Society of Anesthesiologists physical class 2). Pain visual analog scale ratings were comparably high in all groups during the first 2 postoperative hours. Pain intensity ratings at 3 to 12 hours were significantly lower in those who received BUP-i + BUP-b compared with the other treatment groups (P = 0.018). The drug requirement during the postoperative period decreased significantly in all groups (P = 0.01); however, there was a significant difference between groups in the demand:delivery ratio at 3 to 12 hours (group * psydrug interaction, P = 0.026). The numerically lowest demand:delivery ratio was seen with BUP-i + BUP-b. BUP-i was associated with a significantly lower heart rate compared with the other groups (P = 0.027); there were no drug-related differences in respiration rate, SpO(2), or sedation. Patients' level of satisfaction with treatment was significantly higher in the group that received BUP-i + BUP-b compared with the other 3 groups (P < 0.001). Postoperative nausea and vomiting were mild and occurred at a similar incidence in all groups, as did rescue diclofenac use. In these patients undergoing abdominal surgery, the BUP-i + BUP-b regimen controlled postoperative pain as well as did MO-i + MO-b or the combinations of BUP and MO. BUP neither inhibited the analgesia provided by MO nor induced undesired sedation or hemodynamic or respiratory effects.
    No preview · Article · Mar 2009 · Clinical Therapeutics
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Solitary splenic masses are a rare entity. There is a paucity of data in the literature on the evaluation and laparoscopic treatment for splenic masses. To further elucidate the evaluation and laparoscopic management of splenic masses we evaluated our own data. Data was collected retrospectively for all patients who underwent laparoscopic splenectomy (LS) in our institution for the diagnosis of a solid mass. Patients' charts were reviewed. Complementary data was completed when needed by telephone interviews. 28 patients underwent LS for solid splenic masses between 1997 and 2006. Mean age was 54.3 years and 68% were women. Patients' symptoms included abdominal pain (46.5%), anemia (32%), weight loss (21%), and palpable abdominal mass (21%). Fifty-three percent were asymptomatic at diagnosis. Preoperative patients' imaging included computed tomography (92.8%), abdominal ultrasound (71.4%), and positron emission tomography (PET, 32%). Seven patients (25%) had a history of lymphoproliferative disease. The mass size as measured by computed tomography (CT) scan ranged from 4 to 11 cm. Three patients (10.7%) had multiple splenic lesions. Mean operative time was 125 min. Mean estimated blood loss was 200 ml. Five patients (17.9%) had massive splenomegaly. Conversion rate was 14.3%. In three patients (10.7%) the spleen was removed with additional organs' tissue (stomach and pancreas). Two patients (7.1%) were reoperated. There was no postoperative mortality. Mean hospital stay was 4.7 days. Four patients (14.3%) were readmitted due to complications. Pathology revealed eight patients (28%) with benign tumors and the rest (71.4%) with malignant lymphoma. Splenic solid tumor is a rare entity. Most of the cases were eventually diagnosed as malignant tumors. In our series, all malignant tumors were non-Hodgkin lymphoma. The most common benign lesion was inflammatory pseudotumor. This study has demonstrated the feasibility and safety of LS for diagnosis and treatment of both benign and malignant tumors of the spleen.
    Full-text · Article · Aug 2008 · Surgical Endoscopy

Publication Stats

103 Citations
33.45 Total Impact Points


  • 2009-2016
    • Tel Aviv University
      • • Department of Surgery
      • • Sackler Faculty of Medicine
      Tell Afif, Tel Aviv, Israel
  • 2014-2015
    • Meir Medical Center
      Kafr Saba, Central District, Israel
  • 2008
    • Tel Aviv Sourasky Medical Center
      • Division of Surgery
      Tell Afif, Tel Aviv, Israel