תוצאת חיפוש

Portal and Mesenteric Vein Thrombosis after Splenectomy for Idiopathic Thrombocytopenic Purpura

Eldad Silberstein, Alexander Smolikov, Itzhac Levi

Surgery B Dept. and Nathanzon Institute of Radiology, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Mesenteric and portal vein thrombosis are rare complications of splenectomy. Their presentation depends on the underlying disease. It is most frequent in lymphoproliferative disorders but extremely rare in trauma. We describe a 22-year-old man and a 49-year-old woman who underwent splenectomy for idiopathic thrombocytopenic purpura and developed mesenteric and portal vein thromboses. Both were treated successfully with anticoagulants for 3 months until the thrombi regressed, as shown by CT scan. During a year of follow-up they were asymptomatic.

Liver Surgery - Five Years of Experience

Franklin Greif, Moshe Rubin, Eitan Mor, Israel Nudelman, Arnold Sihon, Arie Figer, Alex Belinki, Shlomo Lelcuk

Hepatobiliary Unit and Depts. of Surgery B, Transplantation, Oncology and Radiology, Rabin Medical Center (Beilinson Campus) and Sackler School of Medicine, Tel Aviv University

Major hepatic resections have been associated with significant morbidity and mortality. In the past decade or so this has changed and such procedures are now done in increasing numbers. In the past 5 years we operated on 129 patients with benign or malignant hepatic lesions (75 females, 54 males; age-range 14-84). the reason for surgery was malignancy in 94 (72.9%) and benign lesions in 35 (27.1%). The most common indication for surgery was liver metastases secondary to colorectal cancer in 45% of all patients or 61.7% of those operated for malignancy. Primary liver cancer was the cause for liver resection in 13.2% of all patients or 18.1% for those with malignancy. Of the 35 patients with benign lesions the leading causes for surgery included: giant cavernous hemangioma, simple liver cysts, echinococcus cysts and focal nodular hyperplasia (11%, 22.8%, 20% and 14.3%, respectively).

76 patients underwent anatomical resection and 63 had either a nonanatomical resection or a different operation. Among the former the most common procedure was right hepatectomy (36) and among the later a nonanatomical resection equal to 1-3 Couinod segments (44). Operating time ranged from 55 min. to 8:41 hours with a mean of 3:31‏1:37. Mean hospital stay was 8.7‏5.8 days and 86.8% received between 0-2 units of blood. Overall mortality was 6.2% and 31.2% of the fatalities had cirrhosis. Overall mortality in noncirrhotic patients was 2.6%. The complication rate was 16.3% and only 7 patients (4.4%) were hospitalized in the intensive care unit. This indicates that major liver resections can be done safely, with morbidity and mortality similar to that of other major abdominal operations. 

The Fate of Gallstones "Dropped" during Laparoscopy

Menashe Barzilai, Arie Bitterman, Dorit Schlag-Eisenberg, Nathan Peled

Depts. of Radiology and Surgery B, Carmel Medical Center, Haifa

Laparoscopic cholecystectomy is considered the procedure of choice for removing symptomatic, stone-containing gallbladders. It is estimated that in 30-40% of these operations stone(s) spill into the peritoneal cavity. It was assumed that these "dropped stones" are harmless and are dissolved and absorbed spontaneously. We present a 70-year-old woman in whom such a stone, dropped during laparoscopy, led to formation of an intraperitoneal abscess.

Radiologic Appearance of "Falling Gallstones" during Laparoscopic Cholecystectomy

E. Alkalay, D. Yaffe, Z. Spindel

Eyn Vered Clinic and Depts. of Radiology and Surgery, Sapir Medical Center, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University

Laparoscopic cholecystectomy is the "gold standard" in treating cholelithiasis. Stones are frequently lost in the peritoneal cavity during the procedure, but "missing stones" have been regarded as insignificant. However, there is accumulating evidence that untreated "lost" stones may cause complications even years after operation.

We present a 65-year-old woman who presented with vague complaints, anemia and an elevated ESR. CT scan showed an infiltrating process in extra-abdominal muscles compatible with sarcoma. At operation, 2.5 years after previous laparoscopic cholecystectomy, an abscess was found which contained biliary stones. Because of their small size they were not visible on CT scan. We discuss the possible ways of handling "falling stones."

Extensive Liver Resection: a Series of 72 Cases

Moshe Hashmonai, Doron Kopelman, Ahmed Assalia, Yoram Klein, Hani Bahus, Alex Beny, Yaakov Baruch

Depts. of Surgery B, Oncology and Unit for Liver Diseases, Rambam Medical Center and Technion Faculty of Medicine, Haifa

Partial liver resection is the treatment of choice for various liver diseases, including primary and secondary (metastatic) malignancies, benign tumors, cysts, abscesses, trauma, etc. Improved knowledge of hepatic anatomy and physiology, improved diagnostic techniques and more developed peri-operative treatment have reduced postoperative morbidity and mortality to acceptable levels.

We present a series of 72 liver resections, the majority of which were liver lobectomies or more extensive procedures performed during 1982-1997. The percentage of postoperative complications, which ranged from 1.3% to 19.4%, and mortality (8.3%; 6/72) are comparable to those of other large series in the world literature. We believe that better appreciation of the surgical potential of Israel by our medical community will improve our therapeutic approach to various liver diseases.

Kaleidoscopic Autoimmunity

Yehuda Shoenfeld

Unit for Study of Autoimmune Diseases and Medical Dept. B, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University

We describe an 18-year-old girl with idiopathic thrombocytopenic purpura (ITP) who developed chronic active hepatitis following splenectomy that cured the ITP. This is a phenomenon in which an organ belonging to the immune system is resected, which results in cure of one autoimmune disease but in the emergence of another, apparently unrelated, second autoimmune disease. We refer to this phenomenon as kaleidoscopic autoimmunity, explaining that some autoimmune diseases are not induced by autoantigen-driven mechanisms, but rather result from immune dysregulation.

Nerve Preservation during Superficial Parotidectomy

J. Shvero, I. Koren, R. Feinmesser

Depts. of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center (Beilinson Campus), Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University

Sensory loss in the operative area after superficial parotidectomy is one of the complications which disturbs the patient. The greater auricular nerve, which stems from the cervical plexus, supplies sensation to the area. Sacrifice of the nerve during superficial parotidectomy causes sensory loss in the area. We investigated the degree of sensory loss in the operative area after superficial parotidectomy in 10 patients in whom the posterior branch of the greater auricular nerve was preserved and compared the results with those in whom it was not, a year after operation. There was more sensory loss when the greater auricular nerve was sacrificed. We therefore suggest preserving the posterior branch of the greater auricular nerve during superficial parotidectomy if at all possible.

Combined Treatment of Hepatic Tumors by Cryosurgery and Resection

Doron Kopelman, Alexander Beny, Ahmed Assalia, Diana Gaitini, Yoram Klein, Moshe Hashmonai

Depts. of Surgery B, Oncology and Radiology, Rambam Medical Center and Technion Faculty of Medicine, Haifa

Cryosurgery is an old technique which is being used for hepatic tumors as an adjuvant to hepatic resection. We recently treated 7 patients with multiple malignant liver tumors, 5 of whom had colorectal metastases, 1 carcinoid metastases, and 1 multiple hepatic lesions of hepatocellular carcinoma. 6 underwent combined liver resection and cryoablation of lesions in the remaining liver. In the 7th patient, only cryoablation was performed because hepatic resection was rejected and there was an extrahepatic metastasis. The advantages of this treatment are removal or destruction of all liver lesions found by any method, including intraoperative ultrasound examination, maximal preservation of normal liver parenchyma and that it is curative in patients inoperable by standard criteria.

Splenic Artery Aneurysm

M. Shimonov, M. Nobel, M. Kunichevski, E. Antebi

Depts. of Surgery A and Pathology, Rabin Medical Center, Petah Tikva

Splenic artery aneurysm is an uncommon form of vascular disease of unknown etiology. Its clinical importance is due to its high mortality, especially in pregnancy, when maternal mortality is 70% and fetal mortality 95%. Most cases of splenic artery aneurysm are asymptomatic and are diagnosed incidentally. We present a woman with incidentally diagnosed splenic artery aneurysm in whom the splenic artery and its aneurysm were resected.

Accessibility of Information and Informed Consent: Experiences of Breast Cancer Patients

Ephraim Tabory, Susan Sered

Dept. of Sociology and Anthropology, Bar-Ilan University, Ramat Gan

We studied the social and cultural frameworks that impact on breast cancer patients in the medical system. The subjects were 98 Jewish women who had undergone mastectomy or lumpectomy for cancer 6 months to 3 years prior to the interview. They emanated from a variety of socioeconomic and ethnic backgrounds, and reflected the age range of women with breast cancer in the general Jewish population of Israel. Patients were asked about each stage of the medical process they had experienced: diagnosis, surgery, oncological care, and follow-up care. The interview revealed a general perception of having received insufficient information regarding their medical condition and treatment. The problem tended to be most severe during the diagnostic stage, when women had not yet been officially included as patients within the system. The problem was relatively severe during follow-up care, when they often did not have an address for their questions. Few women received a schedule of follow-up care that allowed them to carry on with the many necessary tests in an orderly and comprehensive manner. Most important, systematic absence of informed consent also characterized the decision-making process regarding surgery and oncological treatment. Few women felt they had been informed about treatment options, side-effects, or long-term implications of the treatment offered. We found no indication of inequitable medical treatment that would suggest a manifest pattern of discrimination, but we did find some social variables related to a feeling of insufficient personal care and information. In particular, older women said they received less attention, support, and information from the medical staff relative to the younger women.

Airbag-Associated Ocular Trauma

Marcus Muallem, Hanna Garzozi

Ophthalmology Dept., HaEmek Medical Center, Afula

Airbags have received widespread recognition as an effective means of enhancing automobile safety. They are particularly effective in frontal and front angle collisions which otherwise would be fatal or cause serious injuries. Inflation of the bag helps protect the driver and front-seat-passenger from hitting the steering wheel, dashboard or windshield. In frontal crashes airbags have reduced driver deaths, hospital admission rates, and incidence of brain injury. On the other hand, an increasing variety of airbag-associated organ injuries has been reported, including blunt ocular and chemical trauma. 2 cases of ocular trauma due to airbags which resulted in choroidal rupture with disastrous outcome in terms of visual acuity are presented. Since the very first report in May 1991 of airbag-associated ocular trauma until June 1996, there has apparently been only 1 case of choroidal rupture due to airbag-associated trauma, presented in 1 sentence of a brief report. Although airbag-related eye trauma may be relatively infrequent, the severity of the injuries incurred, especially when the posterior segment of the eye was involved, warrants research on new airbag design that minimizes the risk of ocular injury. Meanwhile all cases of airbag-associated ocular trauma should be reported, so that medical staff, the general population and car manufacturers will become more aware of this medical issue.

Stromal Uterine Sarcoma arising from Intestinal Endometriosis after Abdominal Hysterectomy and Salpingoophorectomy

Munir Bishara, Eitan Scapa

Institute of Gastroenterology, Hepatology and Nutrition, Assaf Harofeh Medical Center, Zerifin (Affiliated with the Sackler Faculty of Medicine, Tel Aviv University)

The incidence of ectopic endometriosis is 4% to 18%. The intestinal type is quite common with the rectosigmoid the most likely part of the bowel to be involved due to its pelvic location. A 43-year-old woman, whose symptoms, X-ray and endoscopic findings suggested malignancy of the rectosigmoid, is presented. Primary malignancy of the bowel was excluded by endoscopic biopsies. Histological examination at operation showed stromal sarcoma of the uterus with foci of endometriosis. There is no report in the English literature of transformation of intestinal endometriosis into malignancy, such as stromal sarcoma of the uterus, which imitates a primary malignancy with obstruction of the rectosigmoid.

Radical Retropubic Prostatectomy

Ran Katz, Amos Shapiro, Shimon Meretyk, Ezekiel H. Landau, Dov Pode

Urology Dept., Hadassah,University Hospital and Hebrew University,Hadassah Medical School, Jerusalem

Radical prostatectomy may cure most patients in whom the malignant tumor has not invaded through the prostatic capsule. Advances in surgical technique and accumulation of experience have decreased the complication rate significantly. Long-term results of surgical treatment are now better than those of other forms of treatment; hence radical prostatectomy is now recommended for men with life expectancies longer than 10 years. Between 1988 and 1995, 164 men with clinical stages T1 or T2 adenocarcinoma were admitted for radical prostatectomy. Most were not offered a nerve-sparing procedure, so as to allow wider, more complete resection. Those who wanted preservation of sexual function underwent the nerve- preserving procedure. In 6 patients operation was discontinued when metastases to the iliac lymph nodes were detected and in 1 when invasion of the pelvic wall was found. 157 underwent radical prostatectomy. Preoperative biopsy revealed a low-grade lesion (Gleason 2-4) in 19.1%, intermediate grade (Gleason 5-6) in 61.8% and high-grade (Gleason 7-9) in 19.1%; however, pathologic grading revealed that only 7.0% had grade 2-4 tumor, 60.5% grade 5-6 and 32.5% grade 7-9. Pathologic staging revealed T2 tumor in 58%, T3 in 38.8% (including microscopic invasion of the capsule or seminal vesicles); microscopic lymph node metastases were found in 3.2%. Tumor invasion through the capsule was found in only 2 of 13 treated with neoadjuvant androgen blockade, compared with 40% in those who did not receive this treatment. There was no operative mortality and only 14.7% has complications. All had urinary incontinence immediately after operation, but regained continence after an average of 4-5 months. 24 were incontinent for more than 12 months, but most of them had only mild stress incontinence. Most patients were impotent after the procedure. There was tumor recurrence, diagnosed by rise in serum PSA, in 26 during an average follow-up of 26.4 months (range 3-93). Cure rate of prostatic cancer by radical prostatectomy may be increased by improved preoperative staging methods and better patient selection; long term follow up is required for determining cure rate.

Bacterial Culture of Chip Tissue of Enucleated Prostates

I.Z. Ben-Zion, P.M. Dagtyar, J. Kaneti

Urology Dept., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

To assess the prevalence of infection and colonization of the prostate by bacteria, chip tissue samples from 166 patients undergoing retropubic prostatectomy were submitted for bacterial tissue culture. In 28 patients with an indwelling catheter before surgery, E. coli, Klebsiella, Pseudomonas and Enterobacter were the commonest species encountered, the first the most common. In only 7 patients (20%) who didn't have an indwelling catheter before operation was the culture positive. We confirmed that the longer the time the catheter was indwelling before surgery, the greater the likelihood of positive cultures. However, postoperative outcome and morbidity were not related to culture results. We conclude that even though it is worth trying to sterilize the urine and prostate before prostatectomy, the effect on the postoperative outcome is minimal when proper antimicrobial therapy is given perioperatively.

Angioedema Caused by Splenectomy with Malignant Lymphoma Foll-Owed by Multiple Myeloma 7 Years Later

A. Shahar, R. Sharon, M. Lorber, S. Pollack

Institute of Allergy, Clinical Immunology and AIDS and Institute of Hematology, Rambam Medical Center and B. Rappaport Technion- Faculty of Medicine, Haifa

Acquired C1-inhibitor (C1-INH) deficiency has been reported in patients with immunoglobulin abnormalities and lymphoproliferative disorders, and angioedema has appeared simultaneously with the lymphoproliferative disease. We present a 50-year-old woman with acquired C1-INH deficiency and angioedema which preceded by 7 years the diagnosis of malignant mantle cell lymphoma. During the interval she was treated with Danazole and there were no attacks of angioedema. When routine follow-up bone marrow aspiration revealed infiltration of nonspecified lymphoma cells, exploratory laparotomy and splenectomy were performed. A month later Danazol was stopped, C1-INH levels returned to normal and there were no attacks of angioedema. Mantle cell lymphoma consisting of lymphocytes with cytoplasmic IgM-lambda was diagnosed in the excised spleen but chemotherapy was not initiated. 6 months later, a second lymphoproliferative disorder, multiple myeloma IgA kappa, was diagnosed.