תוצאת חיפוש

Laparoscopic Treatment of Small Bowel Obstruction Caused by Adhesions

S. Kyzer, Y. Aloni, I. Charuzi

Surgery Unit B, Wolfson Medical Center, Holon

We describe our experience in 14 patients operated on for small bowel obstruction, who underwent laparoscopic adhesiolysis. In 13 (93%) the obstruction was relieved and only 1 case required conversion to open operation. Bowel activity usually resumed within 24-48 hours, and there were no remarkable intraoperative and postoperative complications. During follow-up none developed recurrent obstruction.

Our experience demonstrates that laparoscopic adhesiolysis is a valid therapeutic option. Additional experience is needed to determine which types of cases are suitable for the procedure.

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.

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. 

Danaparoid-Sodium for Dialysis in Heparin-Associated Thrombocytopenia

Ronen Ben Ami, Ruth Rachmimov, Shlomo Berliner

Medicine Dept. D and Anticoagulation Therapy Unit, Tel Aviv-Souraski Medical Center, and Nephrology Institute, Sheba Medical Center, Tel Hashomer

Danaparoid sodium is an anticomposed of 3 glycosaminoglycans: heparan sulfate, dermatan sulfate and chondroitin sulfate. Similar to heparin, operates by activating antithrombin 3, but does not contain heparin or heparin fragments, and is therefore antigenically distinct.

Danaparoid has been advocated as a safe and effective anticoagulant for heparin-associated thrombocytopenia. However, there is little experience in its use as a substitute for heparin in hemodialysis.

We report 2 men, aged 82 and 73 years, respectively, who developed thrombocytopenia while undergoing hemodialysis with heparin, and who subsequently underwent successful dialysis with danaparoid. There was a rise in platelet levels in both while receiving danaparoid, and dialysis was completed without hemorrhagic or thrombotic complications. Danaparoid is a safe and effective substitute for heparin, and may be used as an anticoagulant in hemodialysis.

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.

Urgent, Unscheduled Self-Referrals by Ambulatory Patients

S. Vinker, S. Nakar, Z. Alon, H. Abu-Amar, G. Sadovsky, E. Hyam

General Sick Fund, Central District and Dept. of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University

Direct self-referral to a consultant is common in the Israeli health system. Yet patients' reasons for their urgent, unscheduled self-referrals for ambulatory consultations (UUSR) have not been explored. We studied such consultations in an urban multi-disciplinary consultation center serving a population of approximately 100,000. Over a 3-month period such consultations in ophthalmology, ear-nose-and-throat and dermatology clinics were treated by a duty family physician (FP). The FP was instructed to focus on the urgent complaint and either to give definitive treatment and schedule a consultation when needed, or refer the patient for immediate specialist consultation. Patients treated by the FP were asked to fill an anonymous questionnaire, which 347/645 (55.4%) did.

Among the reasons for UUSR were that the patient thought that his/her complaints should be treated by a consultant (29%), the patient was sent by the FP without a consultation note (13.9%), the FP was not available (10.4%), or the patient wished to see the consultant for a second opinion (8.2%). In only 7.8% had the patient noted that his complaint needed urgent consultation. Duration of complaints, but not prior efforts to schedule a consultation, were associated with different reasons for asking for an UUSR. For various reasons patients preferred an UUSR rather than seeing their own FP. Patients' opinions regarding self-referrals are important in planning primary care facilities and FP training.

Abnormal Liver Function Tests in the Primary Care Setting

Shlomo Vinker, Sasson Nakar, Emanuel Nir, Eitan Hyam, Michael A. Weingarten

Dept. of Family Medicine, Rabin Medical Center, Sackler Faculty of Medicine; Tel Aviv University; and General Sick Fund, Central District

Results of laboratory tests ordered during a primary care encounter may reveal findings of abnormal liver function tests, including elevated liver enzymes, hyperbilirubinemia, hypoalbuminemia or abnormal coagulation tests. The object of this study was to describe the spectrum of these liver function test (LFT) abnormalities in primary care.

Results of all laboratory tests ordered during 10 months in an urban primary care clinic were retrospectively reviewed and the medical charts of patients with abnormal LFTs were studied. In 217/1088 (20%) of the tests at least 1 LFT abnormality was found in 156 patients. New diagnoses were made in 104 patients. The main diagnostic groups were: non-alcoholic fatty liver changes, Gilbert's disease, acute infectious hepatitis, alcoholic liver disease and cirrhosis and hepatotoxic drug injury. In 60 patients the physician classified the abnormality as negligible and not associated with significant disease. However, an abnormal test that had been ordered for evaluation of a specific complaint, was indeed likely to represent significant disease (X²=29.5, p<0.001). We conclude that finding abnormalities in liver function tests is common in the primary care clinic but does not often indicate significant liver disease.

Acute Gastroenteritis caused by Enterohemorrhagic E. Coli O157:H7

Tuvia Weinberger, Tony Hayek, Shlomo Keidar

Dept. of Medicine E, Rambam Medical Center, and Dept. of Family Care, Haifa and West Galilee, and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

We report a 48-year-old man admitted for watery diarrhea, high fever, chills and abdominal cramps. Entero-hemorrhagic E. coli O157:H7 was isolated. This new, dangerous pathogen causes dysentery and complications such as hemolytic uremic syndrome and thrombotic thrombo-cytopenic purpura. These complications can cause renal failure, neurological deficit and death. Recognition of E. coli O157:H7 infection is important since it causes a rare and dangerous condition. To the best of our knowledge this is the first case reported in Israel.

Fatal Asthma in Children: Preventable?

Haim Bibi, Jamal Mahamid, David Shoseyov, Michael Armoni, Zvika Liss, Menachem Schlesinger

Pediatrics Dept., Barzilai Medical Center, Ashkelon (Affiliated with the Faculty of Health Sciences, Ben-Gurion University of the Negev); Pediatric Intensive Care Unit, Bikur Holim Hospital, Jerusalem, and Kupat Holim Klalit, Darom District

Sudden death from asthma is rare but occurs in the young age group. We recently faced this rare situation, when 3 asthmatic children were dead on arrival at the local emergency room. All 3 had been treated with beta-2 agonist inhalation on a regular basis, without anti-inflammatory treatment. 2 of the children died while inhaling the beta-2 agonist. It is important that there be clear guidelines and full education about the management of asthma, during and between exacerbations, to prevent such deaths.

Prevalence of Pigmentary Dispersion Syndrome in Israel

D. Gaton, A. Barak, S. Segev, Y. Yassur, G. Treister

Ophthalmology Dept., Beilinson Medical Center, Petah Tikva and Ophthalmology Dept. and Institute for Medical Screening and Assessment, Sheba Medical Center, Tel Hashomer

Pigmentary dispersion syndrome is a precursor of pigmentary glaucoma whose prevalence in the urban population of USA was found to be 2.45%. We evaluated its prevalence during ocular screening examinations among normal Israelis. We screened for excessive pigmentation on the corneal endothelium with the slit-lamp and determined in each patient best corrected visual acuity, intra-ocular pressure (after mydriasis), condition of the anterior segment, cup-disk ratio, posterior segment abnormalities and questioned about history of any ocular disease and family history of glaucoma. 374 patients (mean age 49±11) were examined on 10 consecutive days. In 5.9% excessive corneal endothelial pigmentation was found. Intra-ocular pressure (after mydriasis) averaged 15.52±1.93 mm Hg as compared to 14.73±2.04 among the rest of our study population, (p=0.01). The prevalence of suspected pigmentary dispersion syndrome among young adults in Israelis is high.

Oral Anticoagulation Therapy in the Primary Care Setting

Shlomo Vinker, Sasson Nakar, Sergei Finkel, Emanuel Nir, Eitan Hyam

Family Medicine Dept., Sackler Faculty of Medicine, Tel Aviv University; and Shaaraim Clinic, General Sick Fund, Rehovot; Central Cinical Laboratories, and District Medical Director, Central District of the General Sick Fund

The use of oral anticoagulant therapy (OAT) to prevent thromboembolism has been widespread in recent years. The concept of high- and low-intensity regimens has facilitated treatment for many, and has lowered the hazards of overly intense anticoagulation. However, a significant proportion of patients suited to the low intensity regimen are not being treated. It is not clear whether its wider use is limited by continued debate, lack of resources, lack of expertise, or other causes. We retrospectively reviewed the medical records of 32 patients treated with OAT administered in the primary care setting. The average age was 66±11 years (range 34-84). 9 were treated with high-intensity OAT: 8 due to artificial heart valves, and 1 due to a hypercoagulable syndrome with recurrent thromboembolism. 23 were treated with low-intensity OAT, 17 of whom had atrial fibrillation. 11 were also being treated continuously with other medication which interacted with OAT or interfered with other coagulation pathways. Such medication included: aspirin, dipyridamole, amiodarone, bezafibrate and allopurinol. Of 414 coagulation tests, 57% and 65% were in the therapeutic range in the high- and low-intensity OAT groups, respectively. There was no major bleeding event, but in 2 of 8 who bled, gastrointestinal bleeding led to hospitalization. Treatment was discontinued in 1 patient because of difficulties in achieving target INR, and in the 2 hospitalized for bleeding. The percentages of test results in, above and below the therapeutic range were similar to those in other large series, for both intensity regimens. We found that a significant proportion of patients were under chronic treatment with other medication which interacted with OAT. To estimate the rate of complications in primary care OAT, larger series are needed. We conclude that OAT can be given and monitored by the family physician, and that awareness of long and short term drug interactions with OAT is mandatory.

Pediatric Flexible Bronchoscopy

Haim Bibi, David Shoseyov, Michael Armoni, Melly Ohali, Shlomo Pollak, Menachem Schlesinger

Pediatric Dept., Pediatric Emergency Room, Pediatric Day Care Hospital and Immunology and Clinical Allergy Unit, Barzilai Medical Center, Ashkelon; and Bikur Holim Hospital, Jerusalem (Affiliated with the Faculty of Health Sciences, Ben-Gurion University of the Negev)

Between 1993-1996, 200 pediatric flexible bronchoscopies were performed. Indications were: chronic cough (158 children), persistent pulmonary infiltrates (89), recurrent stridor (28), suspected tracheobronchial foreign body (20), suspected tuberculosis (17) and hemoptysis (3). Some children had more than 1 indication. 124 patients were boys (mean 4.18+2.86 years; range 1 month-15 years) and 76 were girls (mean 4.39+2.7 years; range 4 months-15 years). The procedure included direct vision recorded by video-camera and broncho-alveolar lavage; the lavage fluid was sent for culture, Gram and Ziehl-Nielsen stains and for cytology. There were a few minor side effects: mild stridor which resolved within a few hours (10 children) and transient fever (3). This simple, flexible instrument was effective and helpful in the diagnosis and treatment of children with respiratory symptoms in a secondary hospital facility.

Ovarian Cancer In Israel, 1960-1989

Shlomo Mor-Yosef, Relo Avraham, Joseph G. Schenker

Dept. of Obstetrics and Gynecology, Hadassah-University Hospital, Ein Kerem, Jerusalem

In Israel ovarian cancer ranks among the most common malignant diseases in women. It is also one of the main causes of death from cancer in females in this country. Our population is composed of immigrants from diverse social, cultural, and geographical backgrounds, and only a sector of the inhabitants, mainly the younger generation, is Israeli-born. This study evaluates the trends of epidemiological and clinical data on ovarian cancer during 3 decades, 1960-1989, and includes a total of 5,786 cases of ovarian cancer. Information was obtained from the Central Israel Cancer Registry of the Ministry of Health and from the Central Bureau of Statistics. The incidence was stable during the survey period and was about 15-17/100,000 in women over the age of 15. Most (90%) were diagnosed over the age of 40. In women of European/American origin the incidence of ovarian cancer is 3 times greater than in women of Asian/African origin. The rate in the Israeli-born is between those of the other 2 groups, but closer to that of the European/American group. Over 70% were diagnosed with advanced disease (stage III-IV).

Prognosis improved during the period of the study: 5-year survival was 19% in the early 60's and 31% in the 80's. During the last decade of the survey improvement was mainly in 2-year survival (from 38.5% to 60%).