תוצאת חיפוש

Aggressive Surgical Treatment for Cholangiocarcinoma

M. Shimonov, P. Schecter, Y. Avni¹, E. Rabin², A. Rosen, A. Czerniak,

¹Department of Surgery A, Gastroenterology and ²Invasive-Radiology, Wolfson Medical

Center, Sackler Faculty of Medicine, Tel-Aviv University, Israel

Surgery remains the only curative approach to cholangiocarcinoma. Despite operative difficulties concerning tumor location, vascular involvement or hepatic invasion curative resection (i.e. achievement of tumor free margins) carries good survival rates and is associated with low morbidity and mortality. Our experience with 31 patients with cholangiocarcinoma operated during the years 1993-1999 is presented.

Twenty-five patients were found to have hilar cholangiocarcinoma, 3 carcinoma of mid-choledochus and 3 distal cholangiocarcinoma. All patients were evaluated by a diagnostic protocol including laparoscopy and laparoscopic ultrasound. Surgery consisted of local resection of the tumor with Roux en Y hepaticojejunostomy reconstruction. Three patients had concomitant hepatic resection for hilar cholangiocarcinoma while 3 patients had pancreaticoduodenectomy for distal cholangiocarcinoma. Adenocarcinoma was diagnosed in all patients. Curative resection was achieved in 19 patients and palliative resection (microscopically involved resected margins) in 12. One patient died at 60 days postop (3.5% mortality). Postoperative complications included cholangitis occuring in 10 patients who were referred with biliary drains, intraabdominal abscess (2 patients) and biliary leakage (1 patient) all treated conservatively.

Overall survival rate was 82% at one year, 73% at two years and 45% at 5 years. When comparing curative resection with palliative resection, survival rates were 92% versus 71% for 1 year, 72% versus 50% for 2 year and 57% versus 14% for 5 years.

Selection of patients using Laparoscopic Ultrasound combined with aggressive surgical approach enable curative or palliative resection 15 the only treatment modality which is significantly improved survival.

רחל לוינזון, משה הורוביץ ומיכה י' רפופורט

המח' לרפואה פנימית ג', מרכז רפואי אסף-הרופא, צריפין

כשל הכבד המתבטא בצהבת, היפוגליקמיה, אנצפלופתיה, הפרעות בקרישה ועליי הניכרת בטרנסאמינזות, הוא סיבוך מאוחר מוכר של אלח-דם. פחות מוכרת היא פגיעה כולסטטית בכבד שיכולה להקדים אלח-דם. במקרים אלה, אופיינית עלייה של בילירובין ישיר עם עליי הפחותה יותר באנזימי הכבד. עבודות בחיות-מעבדה מראות שעימדון מרה על רקע אלח-דם מתווך על ידי האנדוטוקסין של חיידקים גראם-שליליים ומיגוון ציטוקינים, המשפיעים על ביטוי ותיפקוד נשאים שונים של חומצות מרה ואניונים אורגאניים בתא הכבד. חרף שכיחות התופעה, קיים חוסר בהירות לגבי המאפיינים הקליניים והפרוגנוסטים שלה. אי-בהירות זו גורמת לא פעם לקושי איבחוני ולביצוע הליכים מיותרים. מובאת בזאת סקירת ספרות בנושא הפתופיזיולוגיה והמאפיינים הקליניים של עימדון מרה על רקע של אלח-דם.

יהושע שמר, יהודה שינפלד,

מערכת "הרפואה"

"הרפואה", עיתונם של הרופאים בישראל, משקף את הפעילות הרפואית הקלינית בישראל. מירב ומיטב הרופאים שולחים מאמרים ל"הרפואה" והעיתון המופץ בקרב כל חברי ההסתדרות הרפואית בישראל, מהווה כרטיס ביקור עדכני של המחברים ואמצעי להעברת מידע בין הרופאים והחוקרים. הודות לכך, הגיע עיתון "הרפואה" בשנים האחרונות לרמה מקצועית גבוהה מאוד והדבר בא לידי ביטוי גם במלאכת העריכה הצרופה. כתיבת מאמר מדעי-רפואי היא אומנות לשמה. היא כוללת שלבים רבים, החל מגיבוש הרעיון המרכזי, דרך איסוף החומר, ניתוח הנתונים ועיבודם ועד לדרך הצגת הדברים בצורה מגובשת ובהירה ברמה מדעית הולמת. כתיבה לעיתון "הרפואה" מטילה על המחברים תוספת נכבדה של התייחסות לשפה העברית המהווה מיקטע נוסף במרקם הכולל של מעשה האומנות.

Long-Term Sequelae of Malignant Tumors in Childhood

N. M. Peretz, H. Goldberg, A. Kuten, I. Meller, E. Krivoi, A. Lorber, L. Bentur, A. Lightman, V. Gorenberg, M. Ben Arush-Weyl

Pediatric Hematology-Oncology Dept., Oncology Center, Pediatric Cardiology Unit, Pulmonology and Gynecology Depts., and Pediatric Endocrinology Unit; Rambam Medical Center and Technion-Israel Institute of Technology, Haifa; and Orthopedic-Oncology Unit, Tel Aviv-Sourasky Medical Center and Tel Aviv University

110 children with malignant diseases (leukemia excepted) who survived 5-20 years (median 9) post-therapy were followed (1996-1998). Median age during follow-up was 15 years (range 5-23). The most common malignancies were brain tumors, lymphoma, retinoblastoma and Wilm's tumor.

The 174 late side-effects included endocrine disorders (19%), cognitive impairment (14%), orthopedic dysfunction (12%), alopecia (12%), dental damage (11%), psychological (8%) and neurological (8%) disturbances, and azoospermia or amenorrhea (5%). There was no cardiac or renal damage and no second malignancy.

29% of side-effects were severe. There was significant reduction in quality of life in 54 (49%), in 27 of whom it was severe enough to require psychological intervention. Treatment of brain tumor caused 98 late side-effects in 28 patients (sequelae-to-patient ratio [SPR] 3.3). Most cognitive, endocrine and neurological disorders, and most cases of alopecia, dental and psychological difficulties were in these patients. There were frequent late complications in those treated for retinoblastoma (SPR 1.8), and bone or soft tissue sarcomas (SPR 0.8). Those treated for Wilm's tumor had few side-effects (SPR 0.4).

Late side effects were most frequent after radiation, reaching as high as SPR 2.4. It averaged only 0.5 in those treated with chemotherapy alone or in combination with surgery.

Reduction of late side-effects in these patients requires using less toxic modalities, as long as cure rate is not compromised. When considering secondary strategies, screening for early detection of late complications would enable immediate solutions, such as hormonal replacement or providing compensating skills for post-treatment disability.
 

Metallic Stents for Acute Colonic Obstruction

M. Itkin, E. Atar, H. Neuman, D. Kravarosic, Z. Fuko, M. Kaz

Radiology and General Surgery B Depts., Golda Campus; and General Surgery Dept., Beilinson Campus; Rabin Medical Center, Petah Tikva

The traditional treatment of acute colonic obstruction, usually caused by malignant tumor, is a 2-stage surgical procedure. The first operation is emergent and includes primary tumor resection and end colostomy followed by scheduled colostomy closure. These operations are associated with high mortality and morbidity. Recently, insertion of self-expanding metallic stents for temporary colonic decompression has been was introduced. With this new technique colostomy can be avoided in the acute phase.

In advanced colonic cancer stent-insertion is the only palliative treatment. It is done in the radiology department under fluoroscopic guidance. We present 2 cases of malignant colonic obstruction treated successfully by stent insertion.

Regulation of Natural Medicines in Israel and Abroad

T. Lavy, B. Haran, J. Shemer, S. Shani

Israel Ministry of Health, Pharmaceutical Policy and Economics Unit; Israel Center for Technology Assessment in Health Care; Gertner Institute for Epidemiology and Health Policy Research; Sackler Faculty of Medicine, Tel Aviv University

Hand-in-hand with the public's growing interest in health care, there has been an increasing demand for natural health products considered both safe and medically effective. But many such products have not been shown to meet efficacy and safety criteria and therefore can not be registered as pharmaceuticals. On the other hand, it is quite clear that some products do have pharmacological activity and are being used for therapeutic or preventive effects.

In Israel, the marketing rules for food or dietary supplements prevent their manufacturers from claiming medicinal/healing properties that the product might have, and allow only limited health statements. But great demand for these products has created massive publication attributing medicinal indications for products whose quality, efficacy and safety have neither been examined nor proven according to accepted medical criteria.

We review the regulation and supervision of natural health products in Israel and other developed countries and find a broad range of opinions about natural health products. They range from acceptance as conventional drugs reimbursable by the health insurance, as in Switzerland and Germany, to their status as dietary supplements requiring no significant authorization or supervision, as in the USA.

Analysis of the current situation in Israel and the western world would indicate that some natural health products do possess pharmacological activity and therefore manufacturers should be allowed to make limited claims for specified therapeutic properties. A stricter set of registration regulations are needed for proof of safety, efficacy and quality of these products, but more lenient than those for registering a pharmaceutical product.

Laparoscopic Ultrasound in Predicting Resectability of Choriocarcinoma

M. Shimonov, P. Schachter, G. Gvirtz, Y. Avni, A. Rosen, A. Czerniak

Depts. of Surgery, Ultrasound, and of Gastroenterology, Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University

Cholangiocarcinoma accounts for about 1% of all malignant tumors. They are difficult to diagnose because of their small size and their location. Although surgical resection is the best therapeutic approach, most patients undergo unnecessary exploratory laparotomy due to incorrect preoperative diagnosis.

We present our experience with laparoscopic ultrasound (LU) in the evaluation of cholangiocarcinoma and determination of tumor spread and vascular involvement. Of 25 patients referred for surgery, 6 were excluded following LU and were referred instead for palliative treatment. Diagnosis of the tumor was successful in 92%, and vascular involvement was diagnosed in 46%. LU should be an integral diagnostic test in the evaluation of choriocarcinoma.

Israel Hospital Pharmaceutical Services: A National Survey 

S. Livny, A. Hammerman, S. Shani, J. Shemer

Hiliel Yaffe Medical Center, Hadera; Israel Center for Technology Assessment in Health Care; Gertner Institute, Tel HaShomer; Dept. of Internal Medicine, Sheba Medical Center, Tel HaShomer; and Sackler School of Medicine, Tel Aviv University

Results of a 1996 survey of hospital pharmaceutical services in Israel are presented. A questionnaire was mailed to 46 pharmacy directors in Israel hospitals of which a total of 33 were returned (72%).

The main services provided at hospital pharmacies are production of pharmaceuticals and inventory management. The pharmacy directors estimated that more then half of their pharmacists' time was spent on technical work that did not need their academic, professional knowledge. In Israel general hospitals there are on the average 1.23 full time pharmacist positions per 100 hospital beds and 1.09 positions for other pharmacy employees.

A similar survey carried out in the United States showed an average of 7.4 pharmacists per 100 hospital beds. Pharmacists there have broad clinical roles which, in general Israeli pharmacists do not have.

Computer systems are used in our pharmacies mainly for inventory management. About half of the directors did not think that the location, structure and furnishings of their pharmacy were appropriate for its role.

Under current conditions, Israel hospital pharmacies are not organized to provide pharmaceutical services beyond inventory management and pharmaceutical production. Appropriate budgets and personnel are required to develop clinical pharmacy services at Israel hospitals. This would lead to improved quality of drug treatment and cost-containment and would allow pharmacists to exploit their knowledge, skills and training that under the current system, are only partially utilized.

Cervical Ectopic Pregnancy

Eyal Sheiner, Ilana Yanai, David Yohai, Miriam Katz

Dept. of Obstetrics and Gynecology and Pathology Unit, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Cervical pregnancy is a rare but serious complication. The most frequent presenting symptom is vaginal bleeding, and is thus common in inevitable abortion. Examination reveals a dilated cervix containing products of conception derived from the emptied uterine cavity. The pathologic criteria are cervical glands opposite the placental site, attachment to and actual invasion of the cervix by the placenta, a portion of the placenta below the posterior reflection, and no fetal parts in the corpus uteri. Treatment ranges from hysterectomy to treatment with chemical agents, mostly methotrexate. We present a case of ectopic, cervical pregnancy with exaggerated placental site in the cervix.

Clozapine in the Treatment of Schizophrenia

M. Mark, R. Magnezi, O. Luxenburg, M. Siebzehner, J. Shemer

Israel Center for Technology Assessment in Health Care, Sackler Faculty of Medicine, Tel Aviv University

Schizophrenia is associated with brain abnormalities and is typically evidenced by disorganized speech and behavior, delusions, and hallucinations; it usually requires extended hospitalization. Its incidence in the western world is estimated at 4-7 cases/10,000/year.

A method of shortening hospitalization and improving level of functioning is the use of unique medication, including clozapine, which has been in use in Israel for the past 6 years.

We report 327 patients who participated in a community rehabilitation program and were treated with clozapine. They were compared with 417 patients who corresponded to the guidelines of the Director of Mental Health Services for treatment with clozapine, but were not treated with it for reasons not defined in the guidelines.

The study included those 25-44 and 45-64 years of age and according to the division of the population of patients hospitalized in both government and private hospitals. The project demonstrates the savings from use of clozapine as opposed to the alternative of hospitalizing these patients. It also shows the complexity and difficulty in assimilating new technologies, in relation to the influence of social considerations and supplier/insurer accounting on the patterns of technological assimilation.

Severe Hypercalcemia Due to Renal Transitional Cell Carcinoma

D. Zamir, J. Weizman, N. Erlich, M. Amar, P. Weiner

Depts. of Medicine A, Urology and Pathology, Hillel Yaffe Medical Center, Hadera

Hypercalcemia is a common metabolic disorder, especially in the elderly. The most common etioloare hyperparathy-roidism or malignancy, most often of the lung, breast, kidney or hematological system. Because hypercalcemia is an uncommon manifestation in urinary tract epithelial tumors, especially those of the renal pelvis, we present a man aged 62 years with hypercalcemia due to renal transitional cell carcinoma.

The Israeli Pharmaceutical Market

Segev Shani, Joshua Shemer

Pharmaceutical Policy and Economics Unit, Israeli Center for Health Technology Assessment in Health Care, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

The pharmaceutical market in Israel has undergone many major changes over the past 2 years. We detail measures taken with regard to drug prices and utilization, from 1992 until 1995, when the National Health Insurance Law was implemented. This provides an information base for marketing and dispensing of drugs, economic planning in the public health system, and for physicians and pharmacists in clinical practice.

The national expenditure on pharmaceuticals in 1994 was 9.4% of the annual national health expenditure. From this fact, and the number of registered drugs and the number of clinical trials conducted, it appears that our pharmaceutical market is quite diversified and well developed compared to other markets in the western world. This size advantage enables our sick funds to purchase drugs at much lower prices than the private sector.

Laparoscopy for Common Bile Duct Stones

Ibrahim Matter, Moshe Wald, Shmuel Eldar

Depts. of Surgery and Urology, B'nai-Zion Medical Center, Haifa

We performed 75 laparoscopic cholecystectomies during July and September 1996. In 3 men and 4 women, aged 32-87 years, there was obstructive jaundice caused by choledocholithiasis. During laparoscopy in the jaundiced patients, calculi were identified by cholangioscopy and intra-operative cholangiography. They were washed into the duodenum (confirmed cholangiographically) after intravenous glucagon injections and dilation of the papilla of Vater.

Serum bilirubin and liver enzyme levels returned to normal within a few days. There was no operative or postoperative morbidity, nor any biliary-related systemic complications. Average postoperative hospitalization was 3 days.

Management of Pancreatic Trauma in Damage-Control Laparotomy

Gad Shaked, Mario Golocovsky

Dept. of Surgery and Trauma Service, Soroka University Hospital, Beer Sheba and Dept. of Surgery and Trauma Service, Washington Hospital Center, Washington DC

Major pancreatic trauma challenges the trauma surgeon with diagnostic problems and choices of treatment modalities. The most important determinant guiding management is the integrity of the main pancreatic duct. The preoperative and intraoperative assessment and treatment of pancreatic injury may be difficult, especially when concurrent severe injuries are present. There are alternative approaches in the management of the traumatized pancreas when ductal injury is not obvious during initial exploratory laparotomy.

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.