תוצאת חיפוש

Evaluation of Laparoscopy and Laparoscopic Ultrasound in Pancreatic Lesions

P. Schachter, Y. Avni, A. Rosen, A. Czerniak

Depts. of Surgery A and of Gastroenterology, Wolfson Medical Center, Holon

Pancreatic lesions present a diagnostic challenge. Even modern imaging techniques are not sensitive enough in determining resectability of pancreatic tumors. A substantial proportion of patients therefore undergo unnecessary surgical exploration. We determined the impact of laparoscopy and laparoscopic ultrasound (LAPUS) examinations on surgical decision-making in 60 patients with pancreatic lesions.

Of 48 with solid pancreatic lesions, 22 were defined by LAPUS as having nonresectable tumors, while conventional imaging studies defined only 9 of them as such. 3 of these 9 underwent successful resections of the pancreatic mass. Surgical intervention was ruled out by LAPUS in 16 patients (33.3%) but 26 had resectable lesions of whom 25 underwent surgery. 3 of this group were found to have nonresectable tumors at surgery, a false-positive rate of 6.2%. Overall sensitivity of LAPUS in our series was 88%.

In 12 patients with cystic pancreatic lesions LAPUS contributed significantly to the preoperative decision due to clear imaging of the cystic lesion. Additional information was obtained from ultrasound guided-biopsy of the cyst wall, as well as determination of tumor-marker levels in the cystic fluid aspirate. LAPUS contributed significantly to operative management in 58%.

Laser Treatment of Airway Obstruction in Infants and Children

Y. Efrati, S.M. Sarfaty, S. Kromholz, G. Eshel, M. Weinberg, I. Vinograd

Depts. of Pediatric Surgery, Otolaryngology, Anesthesia and Pediatric Intensive Care, Assaf Harofeh Medical Center, Zerifin (Affiliated with Sackler Faculty of Medicine, Tel Aviv University)

Airway obstruction during infancy and childhood requiring surgical ablation is rare, and surgical intervention poses a significant challenge. During recent decades, appropriate endoscopic instrumentation, together with advanced laser beam technology have provided new operative modalities for such patients.

From 1993 to 1995 we treated 40 infants and children, 26 males and 14 females, 13 days to 11 years old (mean 3.3 years) with Nd-YAG or CO² laser. Obstructing lesions included granulation tissue or polyps (16 cases), septa or webs (27), or benign tumors (4). 7 had more than a single lesion.

All were treated endoscopically under general anesthesia without any operative or postoperative deaths. Surgical intervention removed the obstruction and related symptoms in 34. In 6, laser treatment failed, necessitating additional surgical procedures. 3 had circumferential subglottic web. Operative complications included bleeding during removal of a hemangioma in 1 and recrudescence in another. Postoperative complications were transient respiratory failure and pneumonia in 6, all of which resolved with appropriate treatment.

This series proves that laser technology is feasible in the treatment of airway obstruction during infancy and childhood, and is safe and effective.

Thromboembolism in Orthopedic Trauma

A. Khoury, R. Mosheiff, M. Liebergall

Orthopedic Surgery Dept., Hadassah University Hospital and Hebrew University - Hadassah Medical School, Jerusalem

Trauma increases risk of thromboembolic complications. Thus, in pelvic fractures and spinal injuries the incidence of deep vein thrombosis (DVT) is about 35-60%. Half occur in the pelvic veins and are the most likely to result in pulmonary embolism. While symptomatic pulmonary embolism occurs in 2-10% of patients, more have silent pulmonary embolism. 0.5-2% of pulmonary embolisms are fatal. In lower extremity trauma the incidence of DVT is about 58%, with 18% of them in the proximal veins. Thromboembolic complications are the prime cause of morbidity and mortality among trauma patients, yet they can be prevented efficiently and cost-effectively. The arsenal of prophylactic agents includes heparin, low molecular weight heparin, and mechanical devices including inferior vena cava filters.

Thoracoscopic Splanchnicectomy for Intractable Pancreatic Pain

Joseph Kuriansky, Alejandro Saenz, Laureano Fernandez-Cruz

Dept. of Surgery, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University; and Dept. of Surgery, Clinic Hospital, Barcelona

Intractable pain is the most distressing symptom in nonresectable pancreatic carcinoma and in chronic pancreatitis. Recently, thoracoscopic splanchnicectomy has been advocated as a minimally invasive method of pain control in these patients. Between May 1995 and April 1998, 24 patients with nonresectable pancreatic cancer and 4 with chronic pancreatitis, underwent 43 thoracoscopic splanchnicectomies. All suffered from intractable pain, were opiate-dependent and unable to perform normal daily activities. Unilateral left splanchnicectomy was done in 13 and bilateral in 15.

All procedures were completed thoracoscopically. Operative time ranged from 25 to 60 min and mean hospital stay was 3 days. Median pain intensity was reduced by 50% in 24 and no further narcotics or analgesics were required. We found thoracoscopic splanchnicectomy a safe and effective procedure for intractable pancreatic pain.

Congenital Syphilis: Need for Adequate Antenatal Care

Mark Friedberg

Pediatrics B Dept., Soroka Medical Center, Beer Sheba

Congenital syphilis is well-known and treatable with penicillin. Diagnosis in the neonate and young child may be difficult and consequently morbidity and mortality can be high. Prevention in children is of utmost importance and can be achieved by proper antenatal care and adequate follow-up of pregnant women. This includes identification of pregnant women at risk for contracting syphilis. The case presented demonstrates this need.

Photodynamic Therapy for Dysphagia due to Esophageal Carcinoma

H. Kashtan, F. Konikoff, R. Haddad, M. Umansky, Y. Skornick, Z. Halpern

Dept. of Surgery A and Institute of Gastroenterology, Tel Aviv Medical Center and Sackler Faculty of Medicine, Tel Aviv University

Surgery is the mainstay in the treatment of esophageal carcinoma and is effective for palliation of dysphagia. Patients unfit for surgery are difficult therapeutic problems. We evaluated photodynamic therapy for palliation of dysphagia in this condition.

Patients were given 5-aminolevulinic acid, 60 mg/kg, orally and 24 hour later gastroscopy was performed during which red light illumination (100 j/cmŽ2 for 600 seconds) was administered. This was repeated 48 hours later. The degree of dysphagia was recorded before and 14 days after treatment.

8 patients with an advanced non-resectable tumor, or who were unfit for surgery, were thus treated. 4 had squamous cell carcinoma of the mid-esophagus and 4 had adenocarcinoma of the lower esophagus. There was mild, self- limited photosensitivity in all. Liver and renal function tests and blood count were not affected by the treatment. Dysphagia was improved in all except 1 patient. A patient with early stage disease continued to eat a normal diet.

We believe that photodynamic therapy with systemic aminolevulinic acid as a photosensitizer and a non-laser light source is feasible and safe in advanced esophageal cancer. It is an effective modality for relief of dysphagia in that condition.

Tension-Free Vaginal Tape Procedure for Female Stress Incontinence

David Gordon, Asnat Groutz, Joseph Lessing

Lis Maternity Hospital, Sourasky-Tel Aviv Medical Center

We evaluated the safety and efficacy of the tension-free vaginal tape procedure (TVT) in 20 consecutive women with urodynamically proven genuine stress incontinence. Mean operating time under spinal analgesia was 37.2‏13 minutes and 80% were discharged within 24 hours. There were 5 uncomplicated, intraoperative bladder perforations, but no defects in healing nor tape rejection. The objective cure rate was 95%, while the subjective rate was 100%. Although follow-up was short (9-16 months), the TVT method seems to be safe and effective for stress urinary incontinence.

Evaluation of Asthmatic Children Presenting at Emergency Rooms

Haim Bibi, Elena Shoychet, David Shoseyov, Michael Armoni, Emil Chai, Dorit Ater

Pediatric Pulmonary Clinic and Pediatric Dept., Barzilai Medical Center, Ashkelon; Pediatric Pulmonary Clinic, Bikur Cholim Hospital, Jerusalem; Emergency Room, Barzilai Medical Center, Ashkelon; and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Bronchial asthma in the pediatric age group has become prevalent recently. Many children who suffer from asthma arrive at the emergency room (ER) with exacerbations which did not respond to medical treatment at home.

Between July and December 1997, 136 children 8 months to 14 years of age (61% below 3 years), were studied in our pediatric ER. Investigation included physical examination and pulse oximetry, which were used as guidelines for scoring the children on arrival and post-treatment. Spirometry was done in those who could cooperate. For each patient a detailed questionnaire about medical and sociodemographic factors was filled.

Primary pediatricians used mainly beta-agonist and corticosteroid inhalators, while pediatric pulmonologists used mainly inhaled steroids. There was no relationship between severity of attack on arrival at the ER, mode of treatment and speed of recovery in the ER. More children treated by a general pediatrician more were admitted to hospital. Low parental education and paternal smoking were risk factors for recurrent hospital admissions.

Our results indicate that parents must be educated to stop smoking, especially those with asthmatic children, and primary pediatricians should be updated with regard to proper treatment and follow-up of asthma.

Low Prevalence of Hepatitis G Infection in Dialysis Patients

Doron Zamir, Shimon Shtorch, Chen Zamir, Zvi Fireman, Hilkiau Zonder

Internal Medicine Dept. A, Liver Clinic, Dialysis Unit and GI Unit, Hillel Yaffe Hospital and Hadera Subdistrict Health Office

Prevalence of hepatitis G virus (HGV) infection in the general western population ranges from 0.2-1.5%. In high-risk groups, such as patients with chronic liver disease, hematologic disorders and drug addicts, prevalence is as high as 10%-15%. Dialysis patients have increased rates of HGV infection (6%-50%).

We evaluated prevalence of HGV infection among dialysis patients, and the association between HGV infection and hepatitis C virus (HCV) infection. Serum samples were screened for HGV infection by RT-PCR. Screening for HCV infection was performed by an EIA test and confirmed by RIBA and RT-PCR for HCV. Sera were also tested for HBV markers.

The study group included all 78 hemodialysis patients and 7 of the 12 peritoneal dialysis patients in our unit during September to November 1997. 4 (5.2%) were HGV-positive but none were peritoneal dialysis patients. 1 of the 12 HCV-positives was also infected with HGV. HGV infection was not associated with duration of dialysis, number of blood transfusions or levels of transaminases.

Prevalence of HGV infection among our hemodialysis patients was low (5.2%), but higher than reported for the general population. Prevalence of HGV/HCV infection in hemodialysis patients was low and unrelated to duration of dialysis, number of blood transfusions and levels of transaminases.

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.

One-Stage Surgery for Hirschsprung's Disease in Children

Mark Weinberg, Baruch Klin, Itzhak Vinograd

Dept. of Pediatric Surgery, Assaf Harofeh Medical Center, Zerifin, and Sackler School of Medicine, Tel Aviv University

Traditionally Hirschsprung's disease has been treated by 2-or 3-stage procedures. During the past 6 years a 1-stage Duhamel procedure without stoma has become our treatment of choice for Hirschsprung's disease in neonates and young infants. Over a 6-year period, 15 infants and children with colonic Hirschsprung's disease were treated with the 1-stage Duhamel retro-rectal pull-through procedure without a stoma, with the Lester-Martin modification. All patients had the usual short segment aganglionosis, but 1 had a long segment which included the splenic flexure.

Early complications included wound infection in 1 and minor rectal bleeding in 3. Late complications included constipation in 1 and enterocolitis in 4. Long-term functional results were very good in all those operated except for 1 with rectal achalasia.

We conclude that Hirschsprung's disease can be successfully treated with a 1-stage pull-through operation, the child usually benefitting from the shorter hospital stay and the avoidance of a colostomy.

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.

Severe Pneumonia Caused by Bordetella Bronchiseptica

Taufik Zuabi, Adir Faivisevitz, Michael L. Alkan

Yoseftal Hospital, Eilat; Soroka Medical Center, Tel Hashomer; and Ben Gurion University Center for Health Sciences, Beer Sheba

Bordetella bronchiseptica rarely causes disease in man, and is an unusual pathogen in animals. It causes a pertussis-like syndrome, but pneumonia and sepsis have been described in the immunocompromised as well as in the immunocompetent. A 53-year-old man with adult-onset diabetes and healed pulmonary tuberculosis presented with lobar pneumonia and rapidly developed septic shock with adult respiratory distress syndrome. He responded well to the combination of piperacillin-tazobactam.

Tension-Free Vaginal Tape: A New Surgical Treatment of Female Urinary Stress Incontinence

M. Neuman, B. Zuckerman, M. Zilberman, A. Farkash, U. Beller

Division of Gynecologic Surgery and Oncology, Shaare Zedek Medical Center, Jerusalem

Female urinary stress incontinence diminishes the quality of life of about 5% of women. It is usually dealt with by surgery to correct the relaxed pelvic floor, the cause of the incontinence.

Tension-free vaginal tape is used in a newly described procedure. It consists of the vaginal introduction of a prolene needle-guided mid-urethral sling. The procedure is easy to perform under local anesthesia, recovery is rapid, and results are similar to those of other effective operations.

We report 44 patients who underwent this type of surgery. There were no significant complications. The early results were good and although the follow-up has been short, we believe that experience with this operation will play an important role in the treatment of urinary stress incontinence.

Irritable Bowel Syndrome: Biofeedback Treatment

N. Barak, R. Ishai, E. Lev-Ran

Biofeedback Unit, Psychiatric Ward, Sheba Medical Center, Tel Hashomer

Irritable bowel syndrome is a group of heterogenic complaints of functional bowel disorder in the absence of organic pathology. The pathophysiology is unclear. In most cases treatment includes symptomatic remedies, antidepressants, psychotherapy and hypnotherapy.

Biofeedback has recently been introduced as a therapeutic modality. Treatment also includes relaxation techniques and guided imagery, together with computer-assisted monitoring of sympathetic arousal. Biofeedback requires active participation of patients in their healing progress and leads to symptom reduction in 2/3.