תוצאת חיפוש

Carbon Dioxide Gas Embolism during Laparascopic Cholecystectomy

Anat Laver-Segal, Miguel Iuchtman, Paltiel Weiner

Depts. of Anesthesiology, Surgery A and Medicine A, Hillel Yaffe Medical Center, Hadera and Rappaport Medical School, The Technion, Haifa

A case of carbon dioxide gas embolism during laparascopic cholecystetomy is presented. Prompt diagnosis and immediate treatment resulted in positive outcome. Laparascopic cholecystectomy is nowadays one of the most common operations for cholecystectomy and certainly the most frequent endoscopic surgical procedure. It is usually safe and effective. However, a number of serious complications have been reported during the procedure.

Gas embolism is one of the complications that may occur during the initial gas insufflation or during dissection of the gall bladder. Symptoms are mainly related to the speed and the amount of gas that reaches the venous system. Early recognition and prompt treatment are required to prevent severe morbidity or even fatal outcome.

Transesophageal echocardiography has detected many unsuspected cases of gas embolism. However, capnograph monitoring of end-tidal CO₂, routinely used in everyday anesthesia, is highly reliable in alerting to the possibility of gas embolism and also in confirming its occurrence.

In cases of suspected gas embolism close collaboration between anesthetist and surgeon is required.

Glucosamine Sulfate and Chondroitin Sulfates for Degenerative Joint Disease 

R. Debi, D. Robinson, G. Agar, N. Halperin

Orthopedic Dept., Assaf Harofeh Medical Center, Zrifin

Osteoarthritis results from progressive catabolic loss of cartilage proteoglycans due to imbalance between synthesis and degradation. The availability of glucosamine, an intermediate in mucopolysaccharide synthesis, can be rate-limiting for proteoglycan production in cartilage tissue culture.

57 patients suffering from osteoarthritis of the knee were randomized into a group treated for 4 weeks with daily IV glucosamine sulfate (GS) together with 800 mg chondroitin sulfate, and a placebo group. Knee pain at rest, on movement and on palpation, as well as range of knee motion were then recorded.

In the GS group, there was significant reduction of clinical symptoms (p<0.01), but no significant reduction in the placebo group. Physicians' assessment of tenderness and range of motion were significantly in favor of the GS group (p<0.01). In those treated with glycosamine there were no adverse reactions and no changes in laboratory blood tests.

Microlaparoscopy in Diagnostic and Operative Gynecologic Procedures 

Dov Dicker, Shmuel Nitke, Itai Bar-Hava, Raul Orvieto, Zion Ben-Rafael, Arie Dekel

Depts. of Obstetrics and Gynecology, Rabin Medical Center, Beilinson and Golda Campuses, Petah Tikva; and Sackler School of Medicine, Tel Aviv University

A recent further development in laparoscopic surgery is microlaparoscoopy. The technique is identical to standard 10 mm laparoscopy except for the use of small, 2 mm scopes and trocars. We used this technique in 19 patients treated from June 1998 to February 1999.

The advantages of microlaparoscopy are: smaller incisions, less risk of damage to pelvic organs and less postoperative pain. However, the use of microlaparoscopy for operative procedures is limited to simple operations due to the limited field of vision. We urge our colleagues to consider microlaparoscopy whenever diagnostic laparoscopy is needed.

Follicular Splenic Lymphoid Hyperplasia Associated with EBV Infection

Boleslaw Knobel, Enrique Melamud, Sharon Nofech-Moses, Liliana Zeidel

Dept. of Medicine B and Institute of Pathology, Edith Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University

Massive splenomegaly is defined as a spleen weighing about 10 times normal weight. We describe a 36-year-old man who had huge splenomegaly and secondary pancytopenia simulating malignant lymphoma for about 3 months. Splenectomy was necessary because of the suspicion of hematologic malignancy, especially isolated lymphoma of the spleen, and pain and mechanical abdominal disturbances.

On operation, the spleen was 25 cm long and weighed 250 g. There was florid, reactive follicular lymphoid hyperplasia. Immunohistochemical staining with CD-20(L26), CD-45Ro(UCHL), bcl-2 oncoprotein (Dakopatts), EBV (anti-EBV mol weight 60 KD, Dakopatts) was consistent with reaction to EBV infection and not with follicular lymphoma. Lack of PCR amplification using DNA extracted from paraffin-embedded splenic tissue indicated absence of a monoclonal B cell population carrying rearranged immunoglobulin genes. The lymphocytic population was proven polyclonal by the negative results of PCR for the bcl-2 gene rearrangement. EBV seroconversion from high titer antibodies of anti-EBV-VCA-IgM to negative, and from negative EBNA to positive was consistent with an apparent primary EBV infection.

We have not found on computerized search a previous report of reactive follicular splenic hyperplasia to EBV infection causing huge splenomegaly, with or without EBV-induced infectious mononucleosis.

Breast Conservation: Safe for Early Breast Cancer

Gil Bar-Sella, Georgetta Fried, Zipora Brotman, Anna Ravkin, Riva Borovik, Abraham Kuten

Dept. of Oncology, Rambam Medical Center; Dept. of Oncology, Lin Medical Center; and Rappaport Faculty of Medicine, Technion, Haifa

Between 1981-1993 581 women with primary breast cancer were treated by breast conservation. Their mean age was 56‏12 years and 63% were postmenopausal and 37% pre- or perimenopausal. The median follow-up time was 56 months. 45% had pathological Stage I disease, 49% Stage II, 2.5% Stage III and 3.5% clinical Stage I-II disease. 54% of lesions were excised with good margins, 10% with close margins (<0.5 cm), 9% with microscopic residual, 3% with macroscopic residual, and in 24% margins were not reported. Adjuvant therapy, consisting of combination chemotherapy and/or hormones, was given to 69%.

Radiotherapy, usually 50 Gy tangential photon irradiation to the whole breast, was given to 564 (97%); an electron or photon "boost" to the tumor with a median dose of 17.5 Gy was given to 378 (65%). Most of those with positive nodes received 50 Gy to the lymphatic drainage system.

1 year after radiotherapy cosmetic results were rated as "good" or "excellent" in 80%, "moderate" in 17% and "poor" in 3%. The 5-year actuarial survival was 97% in Stage I and 88% in Stage II. 37 patients (6.5%) developed breast recurrence; 11 of these (2%) had simultaneous distant metastases. 5 (<1%) developed axillary or supraclavicular lymph node metastases, and 81 (14%) developed distant metastases. Most local recurrences were in those younger than 40, and in those with primary tumors >1.75 cm.

The satisfactory level of local control achieved is attributed to the high doses of radiation (up to 75 Gy) administered to those with high risk lesions.

Sensitivity and Resistance of Helicobacter Pylori to Antibiotic Treatment

Benny Avidan, Batia Weiss, Yeuda Chowers, Anita Younash, Simon Bar-Meir, Nathan Keler

Dept. of Gastroenterology and Microbiology, Sheba Medical Center, Tel Hashomer

Resistance to antibiotics is considered the main reason for failure to eradicate Helicobacter pylori (HP). Resistance rates are different in developed and developing countries and are not known for Israel. We studied HP resistance rates in 40 patients who underwent esophagoduodenoscopy for various indications and were found to have gastric HP colonies.

Sensitivity was determined by E-test, using clarythromycin, amoxycillin, clindamycin, erythromycin and metronidazole. The resistance rate for metronidazole was up to 67% but that for clindamycin was only 10%. HP was very sensitive to both macrolide antibiotics, erythromycin and clarythromycin.

Sacral Insufficiency Fractures - A Frequent Cause of Low Back Pain in Elderly Women

H. Semo, Z. Zwas, A. Goshen, S. Levenkrohn, A. Adunsky

Depts. of Geriatric Medicine and Nuclear Medicine, Sheba Medical Center, Tel Hashomer

Sudden low back pain is common in elderly women. It causes physical and mental stress, and results in deterioration of functional movement and in activities of daily living. Awareness of possible sacral insufficiency fracture is important; they may be demonstrated by imaging modalities, mainly radionuclide bone scan. Prognosis is good and accurate diagnosis serves to exclude malignancy and relieve fear of chronic pain and disability. We describe 4 women, aged 84, 82, 71 and 77 who illustrating the clinical and imaging findings of this disorder.

1000 Cardiac Catheterizations in Congenital Heart Disease

Benjamin Zeevi, Galit Bar-Mor, Michael Berant

Cardiac Catheterization Unit, Schneider Children's Medical Center, and Sackler School of Medicine, Tel Aviv University

Over the past 15 years, percutaneous therapeutic cardiac catheterization has become increasingly important in the treatment of congenital heart disease. We describe our experience in 1000 such catheterizations between 1993-1997. 55% were in 1-12-year-olds; only 20% were in patients younger than 1 year old and 11.3% were in adults with congenital heart defects. In about 50% it was at least a second cardiac catheterization. Overall, there were 425 therapeutic cardiac catheterizations, increasing from 33% in the first 200 procedures, to 63% in the last 200.

We performed 30 different types of therapeutic catheterizations: 23.3% were valvular dilations, 21.4% vessel angioplasties, 36.9% closure procedures, 9.2% electrophysiological procedures, and 9.2% miscellaneous. In 31.3% of therapeutic catheterizations we used 12 new procedures. Minor complications occurred in 8.5% and major in 0.6%; most complications were successfully treated or were self-limited and there was no residual damage.

In this report the current role of each type of major catheterization is discussed on the basis of our experience. Further development of technology for lesions not amenable to currently available transcatheter methods, and longer follow-up for current techniques will consolidate the role of therapeutic cardiac catheterization in congenital heart disease.

Malignant Nodular Hidradenoma (Sweat Gland Tumor)

Anat Engel, Yaron Bar-Dayan, Santiago Engelberg, Yair Levi

Depts. of Medicine B, Pathology, and Disease Research Unit, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Malignanhidradenoma is a very rare tumor that originates from sweat glands. We present a 61-year-old man with an ulcerated tumor in his right flank, 4 cm in diameter, that was excised with a wide free margin. Histopathologic study showed an ill-defined, epithelial neoformation, formed by lobules of clear polygonal cells in the deep dermis and subcutaneous tissue, diagnosed as malignant nodular hidradenoma.

1.5 years after excision there was enlargement of the right axillary and inguinal lymph nodes, which showed metastatic, adnexal neoplastic cells. Axillary resection and superficial dissection of the right inguinal nodes were performed. After 3 months the tumor had spread to other lymph nodes and acute obstructive renal failure required insertion of a pig-tail catheter into the right ureter. Radiotherapy was followed by chemo-therapy, but he died from end-stage metastatic disease in multi-organ failure.

Smoking and Incidence of Lung Cancer, 1981-1995

Orna Baron-Epel, Helena Andreev, Micha Barchana, Manfred S. Green

Israel Center for Disease Control, Ministry of Health, Tel Hashomer, Israel; Cancer Registry, Ministry of Health, Jerusalem, and Dept. of Epidemiology and Preventive Medicine, Faculty of Medicine, Tel Aviv University

Smoking is the dominant risk factor for lung cancer. We compared trends in smoking with those of the incidence of lung cancer in Israel. The proportion of smokers has declined during the past 20 years; the decrease is greater in men than in women, and more marked in the elderly. Since 1980 the age-adjusted incidence of lung cancer in Jewish men has decreased slightly, but in women it has remained constant. Among Arab men there was an increase in age-adjusted incidence of lung cancer and since 1986 it has been higher than in Jewish men.

The largest decrease in lung cancer incidence was among Jewish men aged 75 and over. This may be explained by data on the age of smoking cessation in the population. It was observed that the main decrease in smoking occurred among men over the age of 55 in the past 20 years, which correlates with the decline in lung cancer observed in the older age group. Lung cancer rates in Israel are lower than in other western countries despite the similar prevalence of smoking, for unknown reasons.

CT-Guided Excision of Osteoid Osteoma

A. Peyser, S. Porat, T. Sasson, J. Apelbaum, J. Bar-Ziv, E. Sucher

Orthopedic Surgery and Radiology Depts., Hadassah University Hospital, Ein Kerem, Jerusalem

CT-guided excision of osteoid osteoma is a new surgical technique that enables accurate resection of the nidus during 1-day hospitalization. We present 5-year results in 42 patients (26 males and 16 females, mean age 18 years, range 3-46). In 40 out of 42, complaints disappeared immediately after the procedure. The recovery period was short and the return to normal activity was faster than in the open surgical approach. Complications were minimal and transient.

Balloon Angioplasty of Native Coarctation of the Aorta

Benjamin Zeevi, Galit Bar-Mor, Michael Berant

Cardiac Catheterization Unit, Schneider Children's Medical Center, Petah Tikva, and Sackler School of Medicine, Tel Aviv University

The use of balloon dilatation to treat native coarctation of the aorta is gaining acceptance among interventional pediatric cardiologists, but is still controversial. We describe our experience with this procedure in 21 children, mean age 5.6 years and mean weight 21.1 kg. Most had an additional congenital heart defect, most commonly a bicuspid aortic valve. 17 were asymptomatic, 3 had tachypnea and 1 infant had severe congestive heart failure and was ventilated. The mean systolic blood pressure was 129.7 mm Hg.

Balloon dilatation was successful in 90% (19), decreasing the mean maximal systolic gradient from 35.3 to 9 mm Hg (p<0.001), and increasing the narrowest area from 3.9 to 8.2 mm (p<0.001), with a mean balloon-to-coarctation width-ratio of 2.8. There were no complications. Of 15 who underwent repeat cardiac catheterization at a mean interval of 10.6 months, 2 had a maximal systolic gradient of more than 20 mm Hg. 1 of these underwent successful repeat angioplasty and the other, who also had a small aneurysm, underwent surgical repair successfully. 2 others had small aneurysms and they are being followed clinically.

All patients were seen again after a mean interval of 31 months. The mean systolic blood pressure was 104 mm Hg, significantly lower than before intervention (p<0.002). 1 had an increased pressure gradient between right arm and leg of 35 mm Hg at later follow-up, and repeat cardiac catheterization demonstrated a good result 13 months after the initial procedure. She is awaiting a third catheterization. Overall, 90% had good mid-term results.

Based on our experience and recent reports, balloon angioplasty is safe and effective in most children older than 7 months and should be considered a viable alternative to operation for discrete aortic coarctation. Further long-term evaluation is needed.

Percutaneous Closure of Patent Arterial Ducts with Occluding Spring Coils

Benjamin Zeevi, Galit Bar-Mor, Michael Berant

Cardiac Catheterization Unit, Schneider Children's Medical Center, Petah Tikva and Sackler School of Medicine, Tel Aviv University

In recent years percutaneous closure of small and medium- sized patent arterial ducts has been achieved using occluding spring coils. We describe our experience in 93 patients with this tec, using a snare to facilitate the procedure in most. All patients had a clinically apparenpatent arterial duct and had undergone attempts at transcatheter closure at a mean age of 6.8 years. In 1, the duct was a residual lesion following surgical ligation, and in 5 it was a residual following attempted closure with the Rashkind double-umbrella. The mean narrowest diameter of the ducts was 2.1 mm.

In our 93 patients implantation was successful in 92 (99%), using 1 coil (82 patients), or 2 (10 patients), and in 1 by a combination of a double-umbrella device and an occluding spring coil.

The mean fluoroscopic screening time for the whole group was 22.8 minutes, which decreased to 16.8 minutes in the last 50 patients. The coil embolized in 7 patients, but was retrieved in 6 and the ducts were subsequently occluded with another coil. In 1 patient the coil was left in a distal small branch of the left pulmonary artery and the duct was successfully occluded with a double-umbrella.

Color-Doppler echocardiogram performed the morning after placement of the coils showed residual leaks in 18%. At mean follow-up of 24.6 months repeat imaging showed residual leaks in only 3 of these patients (3%).

We conclude that occlusion of small to medium-sized ducts using coils appears to be effective and is the treatment of choice. The use of a snare to hold and manipulate the coil as it is delivered improves control of the coil, the accuracy of its placement, as well as giving complete occlusion of the ducts.

Laparoscopic Repair of Inguinal Hernia Experience in 54 Consecutive Cases

S. Kyzer, I. Kristalni, M. Alis, I. Charuzi

Surgical Dept. B, Wolfson Medcial Center, Holon

We describe our experience in 54 consecutive patients who underwent laparoscopic repair of 86 inguinal hernias. Laparoscopic repair of inguinal hernia is technically feasible, does not prolong the length of the procedure nor of hospitalization and is not accompanied by increased morbidity. Although there is not yet general agreement, in our experience and that of others, it appears that laparoscopic repair will be the preferred approach to the treatment of inguinal hernia.

The Current Compulsory Hospitalization Order and Patients' Rights

Y. Bar-el, R. Durst, J Mazar, J. Rabinowitz, Y. Lerner, H.Y. Knobler

Office of Jerusalem District Psychiatrist; Jerusalem Mental Health Center, Kfar Shaul Hospital; Mental Health Services, Israel Ministry of Health; School of Social Work, Bar-Ilan University; and Falk Institute for Mental Health and Behavioral Sciences, Kfar Shaul (Affiliated with the Hebrew University - Hadassah Medical School)

Israel's "Treatment of Mentally Sick Persons Law" of 1955 was repealed and replaced by the "Treatment of Mental Patients Law" of 1991. Under the latter, the "Compulsory Hospitalization Order" (CHO) defines the new order based on accumulated experience with the old legislation, and on the philosophy that considers the CHO one of the most severely oppressive forms of deprivation of human liberty and rights. The new order sets limits and boundaries for CHO, guarding the rights of those unavoidably committed by force. According to the new law, the district psychiatrist decides upon and issues the order, while the tribunal (District Psychiatric Committee) considers appeals. The order is limited to 1 week, with an option for the district psychiatrist to prolong it on written request for up to 14 days. The tribunal can later prolong the order further.

The objective of this study was to review changes that have occurred following enforcement of the new law in the Jerusalem district. A comparison was made between CHO's issued the year before the new legislation took effect and the year after. The comparison included review of all CHO's and medical files of all patients hospitalized by coercion during 1990 and 1992. It was assumed that there would be a decline in rate and length of hospitalization of patients forced to be committed by the new law.

The main findings refuted this hypothesis. In 1992 there was an increase of 38% in the number of compulsory hospitalizations. This increase derived mainly from increased demands for CHO's from psychiatric emergency rooms. There was also an increase in patients hospitalized by order of the District Psychiatric Committee using its authority under section 10(C) of the law.

Conversely, length of compulsory hospitalization was shorter under the new law.

In light of these findings, it would seem that the new law has only partially fulfilled expectations of reform in individual rights. There is need for further evaluation and follow-up of the CHO in order to determine whether the "Treatment of Mental Patients Law" of 1991 has in fact fulfilled its objectives. Furthermore, it is necessary to determine means, medical or legal, that may possibly advance further the prospective of human rights while maintaining a suitable balance between civil liberties and clinical needs, of over-confinement versus under-treatment, which may lead to neglect or danger.