תוצאת חיפוש

ראובן גורפינקל¹, יובל סלוביק², רונן גלזינגר¹, שלמה וולפיש³,

¹המח' לכירורגיה פלסטית, ²המח' לאף-אוזן-גרון וניתוחי ראש-צוואר, ³היחידה הקולורקטלית, מרכז רפואי סורוקה, באר-שבע

נמק פורנייה הוא מצב של דלקת נימקית של חיתולית (Fascia) דופן הבטן והחיץ, המערבת גם את איברי-המין החיצוניים. דלקת זו נגרמת מזיהום מעורב של חיידקים ארוביים ואנארוביים. ניתוח כריתת טחורים הוא טיפול שיגרתי עם שיעור סיבוכים נמוך. בעבר דווח על חמישה חולים בלבד שלקו בנמק פורנייה כסיבוך מיידי של כריתת טחורים.

המטרות במאמר הנוכחי הן לדווח על מהלך וטיפול בנמק פורנייה כסיבוך מאוחר (7 ימים לאחר ניתוח) של ניתוח לכריתת טחורים בגישה סגורה. כמו-כן, נסקרת הסיפרות הרפואית בנושא ומובא ניתוח של פרשות חולים קודמים שעליהם דווח.

חולה בן 66 שנה, הלוקה בסוכרת שאיננה מטופלת באינסולין, יתר-לחץ-דם ומחלת לב כלילית. אושפז שבוע לאחר ניתוח כריתת טחורים עקב חום גוף גבוה, אודם ורגישות באזור פי הטבעת והפרשה חומה מהצלקת הניתוחית, ועלייה ברמת הליקוציטים בדמו. החולה טופל בהחזר נוזלים לתוך-הווריד, באנטיביוטיקה רחבת טווח, כריתה נרחבת של ריקמת הנמק ופיום הכרכשת. בתרבית מפצע הניתוח צמחו E.coli ותערובת של חיידקים אנארוביים. לאחר שהחלים מהזיהום החד, חולה נזקק להשלמת רקמות חסרות על-ידי שתלי עור וסגירת פיום המעי.

בסקירת הסיפרות נמצאו חמש פרשות חולים עם נמק פורנייה כסיבוך של ניתוח כריתת טחורים. נמצא, כי הסיבוך עלול להופיע גם בבני-אדם ללא מחלות הפוגעות בתיפקוד המערכת החיסונית, וכי לסוג הניתוח לכריתת הטחורים אין השפעה על התהוות הנמק. בכל פרשות החולים המדווחות נגרם הסיבוך ב-48 השעות הראשונות לאחר הניתוח. פרשת החולה המדווח במאמר זה הוא הראשון שבו התהווה נמק פורנייה שבוע לאחר הניתוח.

לסיכום, נמק פורנייה עלול להתהוות כסיבוך מאוחר לאחר ניתוח לכריתת טחורים, ללא קשר למחלות הרקע ולסוג הניתוח שבוצע.

יצחק שרף, רמי הרשקוביץ

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

במאמרים רבים בספרות הרפואית מיוחסת התופעה של נמק בעור כתוצאה של נטילת נוגדי-קרישה כקומדין והפרין. בדיווחים ספורים מדווח על תופעה זו בעקבות טיפול בהפרין נמוך משקל מולקולתי מסוג קלקסן.

המנגנונים האחראיים להשפעת-לוואי זו עקב טיפול בהפרין וקומדין דווחו בדיוק רב, אולם לגבי השפעת-לוואי זו עקב טיפול בקלקסן דווח רק על מנגנונים אפשריים.

מובאת בזאת פרשת חולה שלקתה בנמק בעור כתוצאה מנטילת נוגד-קרישה מסוג קלקסן, ונסקרת הספרות הרפואית בנושא.

Local Necrosis of Finger Following Stab with Needle Used to Pumpterbutaline Sulfate (Bricalin)

M. Yasin, T.H. Vishne, D. Hendel

The Departments of Orthopedics and Surgery A, Rabin Medical Center (Hasharon Hospital) , Petach-Tikva, Israel

Terbutaline sulfate (Bricalin) is a widely used medication for asthma. It works mostly, but not only, on beta-adrenergic receptors.

In this case study we describe a 50-year-old nurse referred to the emergency department after she was stabbed by needle that was used to draw bricalin for inhalation. She arrived at the emergency room with an inflamed necrotic area at the point of the stab. Later, she developed acute infection that was treated with antibiotics. Following the acute phase there was still a necrotic area, that required surgical debridement.

It seems that this is the result of the vasoconstrictive influence of terbutaline sulfate via alpha adrenergic receptors. In the medical literature there is scarce data regarding this side effect.

Limited Percutaneous Surgical Drainage in Severe Neonatal Necrotizing Enterocolitis in Low Birth Weight Prematures

Robert Finaly, Zahavi Cohen, Vadim Kapuller, Agneta Golan, Edna Kurtzbart, Abraham Mares

Depts. of Pediatric Surgery and Neonatology, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

The usual treatment of complicated neonatal necrotizing enterocolitis (NEC) is resection of the necrotic bowel, lavage of the peritoneal cavity and diversion enterostomy. Low-birth-weight premature neonates with this condition are in special danger if general anesthesia and full exploratory surgery is contemplated.

A relatively simple alternate procedure is percutaneous insertion under local anesthesia of a soft abdominal drain, most often in the right lower quadrant. The procedure is done in the neonatal intensive care unit without moving the whole set-up to the operating room.

4 such cases have been treated within the past year. 3 were discharged home as they did not require additional surgical treatment, not having developed intestinal stenosis or obstruction. 1 recovered from the acute episode, but succumbed to a severe intraventricular hemorrhage and respiratory failure 7 days after the procedure.

Our limited but most gratifying experience, in addition to similar experience of others, encourages us to recommend this simple surgical approach in the very sick low-birth-weight premature with fulminant NEC.

Superficial Skin Necrosis in Short Bowel Syndrome

Arie Eisenman, Rafael Enat

Dept. of Medicine B, Rambam Medical Center and Rappaport Faculty of Medicine, The Technion, Haifa

Short bowel syndrome causes a complex of symptoms due to compromise of small intestinal nutrient absorption. A 60-year-old woman underwent major resection of the small intestine due to a road accident 3 years ago. The sole manifestation of short-bowel-syndrome was superficial skin necrosis due to vitamin K deficiency. She was asymptomatic for a long time, until treatment with antibiotics further intensified initially subclinical malabsorption.

It is not clear why there had been no other symptoms and why the main impact was on the fibrinolytic system rather than the coagulation system, as is usually the case. It is recommended that patients after major resection of the small intestine be closely monitored for coagulation function if an oral antibiotic is prescribed.

Intestinal Transplantation: World Experience and Future Perspective

Eytan Mor, Moshe Rubin, Yaron Niv

Depts. of Transplantation, Surgery B and Gastroenterology Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva

Intestinal transplantation, which until recently has been considered an experimental procedure, is now undergoing considerable change and becoming a standard treatment for patient with intestinal failure. The major improvement in results is due to the introduction of new immunosuppressive agents that have led to significant reduction in acute rejection. Nevertheless, reduction in severe infectious complications, which are the main cause of mortality after transplant, as well as improved techniques for early diagnosis of rejection are needed before intestinal transplantation can be widely used.

We describe our experience in post-transplant follow-up of a woman, aged 32-years, who had undergone intestinal transplantation for short bowel syndrome after extensive bowel resection.

The Diagnosis and Treatment of Fournier's Gangrene

M. Cohen, E. Tamir, S. Abu-Abid, Y. Galili, M. Giladi, S. Avital, R. Shafir, Y. Klausner

Surgery and Infectious Disease Depts. and Division of Surgery, Tel Aviv-Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

We treated 2 women and 8 men suffering from Fournier's gangrene during 1990-96. 2 had diabetes, 1 suffered from ulcerative colitis and 1 was an alcoholic. In 8 of them the infection was triggered by a mixture of aerobic and anaerobic bacteria. Treatment consisted of repeated wide debridement and early colostomy. This aggressive approach resulted in relief of the septic signs within 24 hours and permitted early skin grafting of the wounds. 2 patients died due to sepsis that caused multiple organ failure. The 8 who survived were hospitalized for an average of 35 days. On follow-up examination 1-5 years later all patients had undergone closure of the colostomy and were completely rehabilitated.

Fournier's gangrene is not rare in the geriatric population. We believe that early diagnosis and aggressive wide debridement, combined with early colostomy, are the keys to successful treatment.

Necrotizing Soft Tissue Infection

E. Rath, I. Shelef, E. Avinoah, Y. Lichtman, O. Levy, D. Atar

Depts. of Orthopedics, Diagnostic Radiology and General Surgery C, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

The dramatic course of necrotizing soft tissue infection represents a medical emergency, since it is limb - and life-threatening. Most necrotizing soft tissue infections are caused by mixed aerobic and anaerobic Gram-negative and Gram-positive organisms. Most case have been reported in immunocompromised hosts after penetrating trauma or surgery. We describe a unique series of cases of necrotizing soft tissue infection. The mainstay of treatment is early and daily debridement of devitalized tissue and broad-spectrum antibiotics. Hyperbaric oxygen therapy should be considered.

Maggot Therapy for Gangrene and Osteomyelitis

K.Y. Mumcuoglu, M. Lipo, I. Ioffe-Uspensky, J. Miller, R. Galun

Dept. of Parasitology, Hebrew University-Hadassah Medical School, Jerusalem

5 patients with diabetic-foot were treated by maggot therapy. The most serious case was in a 75-year-old man who had gangrene and osteomyelitis of the right foot. Proteus mirabilis, Enterococcus sp., Providencia stuartii and Staphylococcus spec. (coagulase positive) were isolated from lesions which did not respond to antibiotic therapy. The patient had twice refused amputation but agreed to maggot therapy. Larvae of the sheep blowfly Phoenicia (Lucilia) sericata were used for twice-weekly treatment over a period of 7 months. Sterile larvae were applied to the wound and replaced every 3-4 days. After 4 months of treatment, the necrotic tissue around the toes and on the sole of the foot detached from the healthy tissue. During the last 3 months of treatment the larvae removed the remaining infected tissue. As therapy progressed, new layers of healthy tissue covered the wound. The offensive odor associated with the necrotic tissue and the intense pain in the foot decreased significantly. At the end of therapy, during which there were no complaints of discomfort, he was able to walk. In the 4 other patients who had relatively superficial gangrene, the maggots debrided the wounds within 2-4 weeks. Thereafter treatment was continued with antibiotics. Maggot therapy can be recommended in cases of intractable gangrene and osteomyelitis, when treatment with antibiotics and surgical debridement have failed.