Israel Medical Association Journal

Background: Debate continues in Israel as to whether to allow patients in public hospitals to choose their physician in return for an additional, out-of-pocket payment. One argument against this arrangement is that the most senior physicians will devote most of their time to private patients and not be sufficiently available to public patients with complex cases.

Objectives: To analyze the patterns of surgical seniority in Jerusalem hospitals from a number of perspectives, including the extent to which: a) opting for private care increases the likelihood of being treated by a very senior surgeon; b) public patients undergoing complex operations are being treated by very senior surgeons, c) the most senior surgeons allocate a significant portion of their time to private patients.

Methods: Demographic and clinical data were retrieved from the operating room records of three of the public hospitals in Jerusalem for all 38,840 operations performed in 2001. Of them, roughly 6000 operations (16%) were performed privately. Operations were classified as "most complex," "moderately complex" and "least complex" by averaging the independent ratings of eight medical and surgical experts. The surgeon's seniority was graded as "tenured" (tenured board-certified specialists, including department heads), "senior" (non-tenured board-certified specialists), and "residents." For each operation, we considered the seniority of the lead surgeon and of the most senior surgeon on the surgical team.

Results: The lead surgeon was of tenured rank in 99% of the most complex private cases and 74% of the most complex public cases, in 93% of the moderately complex private and 35% of the moderately complex public cases, and in 92% of the least complex private and 32% of the least complex public cases. The surgical team included a tenured physician in 97%, 66%, and 53% of the most complex, moderately complex, and least complex public operations, respectively. In both private and public cases, a board-certified (tenured or senior) specialist was a member of the surgical team for almost all of the most complex and moderately complex operations. On average, over half of the operations in which the lead surgeon was a department head were performed on public patients. Among tenured surgeons, those who spent more hours than their colleagues leading private operations also tended, on average, to spend more hours leading public operations.

Conclusions: Private patients have an advantage over public patients in terms of the seniority of the lead surgeon. However, there is also substantial involvement of very senior surgeons in the treatment of public patients, particularly in those cases that are most complex. 

Background: Ischemic mitral regurgitation is associated with reduced survival after coronary artery bypass surgery.

Objectives: To compare long-term survival among patients undergoing coronary surgery for reduced left ventricular function and severe ischemic MR[1] in whom the valve was either repaired, replaced, or no intervention was performed.

Methods: Eighty patients with severe left ventricular dysfunction and severe MR underwent coronary bypass surgery. The mean age of the patients was 65 years (range 42–82), and 63 (79%) were male. Sixty-three (79%) were in preoperative NYHA functional class III-IV (mean NYHA 3.3), and 26 (32%) were operated on an urgent/emergent basis. Coronary artery bypass surgery was performed in all patients. The mitral valve was repaired in 38 and replaced in 14, and in 28 there was no intervention. The clinical profile was similar in the three groups, although patients undergoing repair were slightly younger.

Results: Operative mortality was 15% (8%, 14%, and 25% for the repair, replacement and no intervention respectively; not significant). Long-term follow up was 100% complete, for a mean of 38 months (range 2–92). Twenty-nine patients (57%) were in NYHA I-II (mean NYHA 2.3). Among the surgery survivors, late survival was improved in the repair group compared to the other groups (P < 0.05). Predictors for late mortality were non-repair of the mitral valve, residual MR, and stroke (P = 0.005).

Conclusions: Patients with severe ischemic cardiomyopathy and severe MR undergoing coronary bypass surgery should have a mitral procedure at the time of surgery. Mitral valve repair offers a survival advantage as compared to replacement or no intervention on the valve. Patients with residual MR had the worst results.

Objectives: To review the current status of MAS[1] in a pediatric tertiary care center in Israel, in terms of feasibility, safety, and effect on standard practices.

Methods: We reviewed the files of all children who underwent a MAS procedure in our department during the period April 2002 to July 2004, and compared the findings with those of children treated by standard practices.

Results: A total of 301 procedures were performed in 271 patients: 107 thoracoscopic and 194 laparoscopic. There were no major intraoperative complications. The total conversion rate was 3.65%: 0 for thoracoscopy and 5.6% for laparoscopy (11/194). Twenty-four types of procedures were performed during the study period. The thoracoscopies accounted for 92.24% of all thoracic procedures in the department (107/116), and routine abdominal laparoscopic procedures replaced open surgery in 30–100% of cases (total 44.8%, 194/433).

Conclusions: MAS procedures appear to be safe for a wide range of indications in children. In our center they currently account for a significant percentage of pediatric surgeries. We suggest that the integration of MAS training in the residency programs of pediatric surgeons be made a major long-term goal. The creation of a pediatric MAS study group, which would allow for multi-institutional studies, is especially important in Israel where a relatively large number of pediatric surgery departments handle a small annual number of patients.

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[1] MAS = minimal access surgery

Objectives: To compare the hemostatic efficacy of the second-generation surgical sealant (Quixil™ in Europe and Israel, Crosseal™ in the USA) to that of nasal packing in endonasal surgery.

Methods: We conducted a prospective randomized trial that included 494 patients (selected from 529 using exclusion and inclusion criteria and completed follow-up) undergoing the above-mentioned endonasal procedures. Patients were assigned to one of three surgical groups: septoplasty + conchotomy + nasal packing or fibrin sealant (Group 1); ESS[1] + nasal packing or fibrin sealant (Group 2); and ESS + septoplasty + conchotomy + nasal packing or fibrin sealant (Group 3). The hemostatic effects were evaluated objectively in the clinic by anterior rhinoscopy and endoscopy and assessed subjectively by the patients at follow-up visits.

Results: Postoperative hemorrhage occurred in 22.9–25% of patients with nasal packing vs. 3.12–4.65% in the fibrin sealant groups (late hemorrhage only). Drainage and ventilation of the paranasal sinuses, which are impaired in all cases of packing, remained normal in the fibrin sealant group. There were no allergic reactions to the sealant.

Conclusions: Our results show that fibrin sealant by aerosol spray in endonasal surgery is more effective and convenient than nasal packing. It requires no special treatment, i.e., antibiotics, which are usually used if nasal packing is involved.

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[1] ESS = endoscopic sinus surgery

Objectives: To evaluate the accuracy of 16-slice multi-detector CT angiography in the diagnosis of coronary artery disease, and assess coronary bypass grafts and coronary anomalies.

Methods: We conducted a retrospective study of 223 patients who were examined at our medical center over a period of 2 years with a 16-slice CT angiography scanner and retrospective electrocardiographic gating.

Results: There were no significant complications, and good visualization of the coronary arteries was achieved in all but eight patients. A high correlation with the results of the invasive angiography was noted (sensitivity 85%, specificity 93%, negative predictive value 98%). Altogether, 131 bypass conduits were examined with excellent graft visualization. Several coronary anomalies were detected, as were significant extra-cardiac findings.

Conclusions: Multi-slice CT angiography is a reliable non-invasive diagnostic procedure for demonstration of the coronary arteries and bypass grafts. In the future it will probably replace part of the diagnostic invasive coronary angiography and, as a result, a large proportion of coronary angiography procedures will be therapeutic.

Objectives: To analyze our 8 year experience using TEM[1] for the management of rectal cancer.

Methods: Local resection by TEM was performed in patients with benign tumors and early rectal cancer. In addition, selected patients with T2 and T3 rectal cancers who were either medically unfit or unwilling to undergo radical surgery were also treated with this modality. Radical surgery was offered to all patients with incomplete tumor excision by TEM.

Results: Overall, 116 TEM operations for rectal tumors were carried out between 1995 and 2003, including 74 patients with rectal adenomas and 42 patients with rectal carcinomas. Twenty-five patients had T1 tumors that were all successfully removed, with clear tumor margins, by TEM. Fourteen patients had T2 cancer and 3 of them (21%) required additional radical surgery due to incomplete excision. Local recurrence was observed in one patient with T2 cancer. There was no mortality. Major surgery, or radiotherapy-related complications requiring additional surgical intervention was needed in five patients with T2 cancer.

Conclusions: Local excision by TEM is a safe surgical procedure and should be offered to highly selected patients with early rectal cancer.

Objective: To investigate the effectiveness of preoperative chemoradiation in increasing the resectability rates of rectal cancer and increasing the anal sphincter preservation rate.

Methods: The study group included 66 patients aged 33–84 years with T₂–T₃ rectal carcinoma who were treated in our institute from 1997 to 2002 with preoperative chemoradiation followed by surgery 6 weeks later. All patients underwent preoperative transrectal endoscopic ultrasound for tumor staging and localization. The duration of follow-up was 25 months.

Results: Chemoradiation led to tumor downstaging in 61 patients (92.4%), all of whom underwent low anterior resection. Only 11.4% of this group needed a temporary (6 weeks) loop colostomy/ileostomy. None of the 16 patients with post-treatment T₀ tumors had evidence of malignant cells on pathologic study. Five patients (7.6%) failed to respond to chemoradiation and underwent APR[1]. There were no major complications, such as leakage, and no deaths.

Conclusions: Neoadjuvant chemoradiation is an effective modality to downstage advanced rectal cancer, improving patient quality of life by significantly reducing the need for a terminal permanent colostomy, or even a temporary one.

Objective: To evaluate the contribution of the sestamibi-SPECT (MIBI) localization, cervical ultrasonography, and intraoperative rapid turbo intact parathormone assay in minimal invasive parathyroidectomy.

Methods: Between August 1999 and March 2004, 146 consecutive hyperthyroid patients were treated using the MIBI and ultrasound for preoperative localization and iPTH[1] measurements for intraoperative assessment.

Results: Parathyroid adenoma was detected in 106 patients, primary hyperplasia in 16, secondary hyperplasia in 16, tertiary hyperplasia in 5 and parathyroid carcinoma in 1 patient. Minimal invasive exploration of the neck was performed in 84 of the 106 patients (79.2%) with an adenoma, and in 17 of them this procedure was performed under local cervical block anesthesia in awake patients. Adenoma was correctly diagnosed by MIBI scan in 74% of the patients, and by ultrasound in 61%. The addition of ultrasonography to MIBI increased the accuracy of adenoma detection to 83%. In 2 of the 146 patients (1.4%) iPTH could not be significantly reduced during the initial surgical procedure. Minimal invasive surgery with minimal morbidity, and avoiding bilateral neck exploration, was achieved in 79.2% of patients with a primary solitary adenoma.