Israel Medical Association Journal

Background: Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis.

Objectives: To evaluate the long-term functional outcome of patients who underwent this surgical procedure.

Methods: We performed this observational study in 174 consecutive patients: 146 with UC[1] and 28 with FAP[2]. The patients, 91 males and 83 females with a mean age of 34.1 ± 10.6 years (range 6–67 years), underwent the procedure between January 1984 and January 2004 (mean follow-up 64.8 months, range 1–240 months). The indications for surgery were intractable disease in 124 patients (71%), dysplasia in 36 (21%), severe bleeding in 8 (5%), and perforation in 6 (3%).

Results: A protective ileostomy was performed in 140 patients (96%) with UC and 12 (43%) with FAP. An urgent three-stage procedure was necessary in 14 patients (8.4%). A mucosal proctectomy was performed in 94 (54%), and a double stapling technique in 80 (46%). Mean length of hospital stay was 9.4 ± 6.6 days (range 5–34 days, median 8). Complications included pelvic sepsis in 7 patients (4.2%), anastomotic leakage in 8 (4.8%), bowel obstruction in 22 (13.2%), incisional hernia in 12 (7.2%), anastomotic stenosis that usually responded to manual dilatation in 46 (27.6%), pouchitis in 106 (61%), recto-vaginal fistula in 3 (1.8%), retrograde ejaculation in 3 (1.8%), and impotence in 2 (1.2%). There was no mortality in this group of patients. The median number of bowel movements per 24 hours was six in UC patients and five in FAP patients, with at least one bowel movement during the night. Complete daytime and night-time continence was documented in 124 patients (71%). Overall satisfaction was 95%.

Conclusions: Restorative proctocolectomy with ileal pouch-anal anastomosis confers a long-term good quality of life to both UC and FAP patients, and the majority of patients are fully continent with five to six bowel movements per day. 

Background: Follow-up examinations in a rehabilitation center clinic after stroke are essential for coordinating post-acute services and monitoring patient progress. Of first-stroke patients discharged from our rehabilitation ward to the community 92% are invited for ambulatory check-up once every 6 months.

Objectives: To review patient complaints at follow-up and the recommendations issued by the attending physical medicine and rehabilitation specialist at the outpatient clinic.

Methods: We extracted relevant data from the records, and assessed the relationship between functional status on admission and discharge (measured by FIM[1]), length of stay, and number of complaints. Patients were divided according to the side of neurologic damage, etiology, whether the stroke was a first or recurrent event, and main clinical syndrome (neglect or aphasia).

Results: Patients' complaints included: decreased hand function (40%), general functional deterioration (20%), difficulty walking (11%), speech dysfunction (10%), various pains (especially in plegic shoulder) (8%), urine control (2%), sexual dysfunction (3%), swallowing difficulties (2%), and cognitive disturbances (2%). Patients received the following recommendations: physiotherapy (52.5%), occupational therapy (37.5%), speech therapy (12.5%), different bracing techniques (22.5%), pain clinic treatment (12.5%), changing medication prescriptions (7.5%), psychological treatment (10%), sexual rehabilitation (5%), vocational counseling (2.5%), counseling by social workers (2.5%), and recurrent neuropsychological diagnosis (2.5%). A reverse correlation was found between the number of complaints and FIM at admission (P = 0.0001) and discharge (P = 0.0003), and between LOS[2] and FIM at admission (P = 0.0001) and discharge (P = 0.004). A direct correlation was found between the number of complaints and LOS (P = 0.029). No relation was found between age, type of stroke, first and recurrent event, and clinical syndromes and patient complaints in the outpatient rehabilitation. Community rehabilitation services met 58% of all recommendations in 62% of patients, mainly physiotherapy and occupational therapy, with 34% of patients waiting for implementation of the recommendations and 4% not available for follow-up.

Conclusions: Follow-up examinations should be an integral part of post-stroke rehabilitation. Rehabilitation treatment in the community must be strengthened.

Background: The World Health Organization considers a country's morphine consumption to be an important indicator of progress in pain relief. Despite the strong consensus favoring the use of opioids in many types of pain, limited data are available for gauging the trends in opioid usage in specific medical institutions, such as hospitals

Objectives: To assess the possibility that monitoring opioid consumption can shed light on directions and trends in the treatment of pain in a hospital setting.

Methods: Data on opioid consumption, number of inpatient days, and number of operations performed each year during the period 1990–1999 were obtained from records kept in the hospital’s pharmacy and archives.

Results: During that decade the overall opioid consumption in the hospital increased from the equivalent of 3.7 mg of oral morphine per inpatient day to 7.3 mg, and from 56 mg per surgical procedure to 100 mg. In 1990, injected opioids accounted for 93% of the overall consumption, whereas in 1999 they accounted for only 44%. Yet, the proportion of injected meperidine to injected morphine increased only from 43% to 51%.

Conclusions: These results suggest that the ongoing monitoring of opioid consumption can highlight trends and directions and possibly emphasize strengths and weaknesses in the treatment of pain in hospitals.

Background: Developments in laparoscopic surgery have rendered it an efficient tool for many complex surgical procedures. In the last few years, laparoscopic adrenalectomy has become a more viable option for removal of adrenal pathology, with many surgeons preferring it to the conventional open technique.

Objectives: To describe the indications, technique, complications and follow-up of patients undergoing laparoscopic adrenalectomy in our department.

Methods: The hospital files of 30 patients who underwent the procedure were reviewed. There were 19 females and 11 males with a mean age of 45 years. Indications for surgery differed and included hypersecreting adenoma, pheochromocytoma, suspected malignancy, and incidentaloma.

Results: Of the 31 laparoscopic adrenalectomies performed, 11 were right, 18 were left, and 1 was bilateral. The conversion rate to an open procedure was 3%. The mean duration of procedure was 120 minutes. Only one patient required blood transfusion. Complications occurred in 20% of patients, all reversible. There was no mortality. Mean hospitalization duration was 3.4 days, and median follow-up 17 months. There were no late complications. All patients operated on for benign diseases are alive.

Conclusions: Laparoscopic adrenalectomy appears to be a useful tool for the treatment of a range of adrenal pathologies.

Background: Coronary stenting was recently introduced as a primary intervention for acute myocardial infarction. Several randomized controlled studies have shown that stenting may be superior to balloon angioplasty for the treatment of AMI[1]. However, routine stenting may also cause deterioration of coronary flow.

Objective: To analyze the clinical characteristics and the outcome of patients who were treated with stenting for AMI in our center in the recent era of stenting.

Methods: Fifty-five patients with AMI were treated by stent implantation between January 1998 and December 1999. Adverse clinical events were recorded, including death, recurrent infarction, coronary artery bypass grafting, cerebrovascular accident, and target vessel revascularization. In-hospital, 1 month, 6 month and 1 year follow-up was performed in all patients. Repeated coronary angiography was performed according to clinical indications.

Results: Baseline angiographic results showed Thrombolysis in Myocardial Infarction (TIMI) 0 flow in 39 patients (70.9%), TIMI I flow in no patient and TIMI II/III flow in 16 patients (29.1%). TIMI grade 3 flow was achieved in 90.9% of patients at the end of the procedure. In-hospital mortality rate was 5.4% (2.1% in patients without cardiogenic shock). There was no evidence of re-infarction or TVR[2]. The rates of bleeding complication (all of them minor), CVA[3], and CABG[4] were 9.1%, 3.6% and 1.8% respectively. The 6 month mortality rate remained the same. Rates of re-infarction, restenosis, TVR and CABG were 3.6%, 14.5%, 14.5% and 5.4% respectively. The 1 year mortality rate was 7.3%. Restenosis rate was 18% and CABG 7.3%. One year event-free survival was 70.9%.

Conclusions: This study suggests that stenting is a safe and effective mode of therapy in the setting of AMI associated with a high rate of revascularization and a low short and long-term outcome.

Background: Damage to the intervertebral disk is usually corrected by means of a prosthesis.

Objectives: To report the outcome of the artificial lumbar disk replacement with the Charité SB III disk prosthesis in 20 patients after a 48 month follow-up.

Methods: The 20 patients were evaluated clinically and radiographically during this period. Preoperative diagnosis included degenerative diskopathy in 17 patients and failed posterior conventional diskectomy in 3. The prosthesis was implanted at one level in 17 patients and bi-level implantation was performed in the other 3 patients.

Results: Eighty percent of patients reported satisfactory to very good results. Poor results were reported by four patients, one of whom underwent posterolateral fusion and another is waiting for the same operation. There were two dislocations of the prosthesis followed by immediate revision surgery.

Conclusions: Contraindications for surgery appear to be the principal cause of failure rather than the prosthesis itself.
 

Background: The implementation of treatment guidelines is lacking worldwide.

Objectives: To examine whether follow-up in a specialized lipid clinic improves the achievement rate of the treatment guidelines, as formulated by the National Cholesterol Education Program and the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Methods: The study group included patients who were referred to the lipid clinic because of hyperlipidemia. At each of five visits over a 12 month period, lipid levels, liver and creatine kinase levels, body mass index, and adherence to diet and medications were measured, and achievement of the NCEP[1] target level was assessed.

Results: A total of 1,133 patients (mean age 61.3 years, 60% males) were studied. Additional risk factors for atherosclerosis included hypertension (41%), type II diabetes mellitus (21%), smoking (17%), and a positive family history of coronary artery disease (32%). All patients had evidence of atherosclerotic vascular disease (coronary, cerebrovascular or peripheral vascular diseases). The low density lipoprotein target of <100 mg was present in only 22% of patients before enrollment, with improvement of up to 57% after the follow-up period. During follow-up, blood pressure control was improved (from 38% at the time of referral to 88% after 12 months, P < 0.001), as was glycemic control in diabetic patients (HgA₁C improved from 8.2% to 7.1% after 12 months, P < 0.001). Improved risk factor control was due to increased compliance to medication treatment (from 66% at enrollment to more than 90% after 12 months), as well as careful attention to risk factor management that translated into a change in the treatment profile during the follow-up. There was an increase in the use of the following medications: aspirin from 68% to 96%, statins from 42% to 88%, beta blockers from 20% to 40%, and angiotensin-converting enzyme inhibitors from 28% to 42%; while calcium channel blocker use decreased from 40% to 30% in patients during follow-up.

Conclusion: Follow-up of patients in a specialized clinic enhances the achievement of LDL[2]-cholesterol treatment goals as well as other risk factor treatment goals, due to increased patient compliance and increased use of medications.

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Background: Long-term follow-up in apical hypertrophic cardiomyopathy is rare.

Objective: To study the natural history of the disease.

Methods: We followed 11 patients, 5 women and 6 men, for 5-20 years.

Results: At presentation all 11 patients had typical features of apical hypertrophic cardiomyopathy, with dyspnea in 3 and chest pains in 8, of whom 5 were typical of angina and 3 had myocardial infarction. R-wave voltage and T-wave negativity progressively decreased in magnitude at serial electrocardiograms in four patients. Perfusion defects were detected on thallium myocardial scintigraphy in three, increased apical uptake in two, and normal in one patient. Apical aneurysm with normal coronary arteries developed in a patient who had sustained ventricular tachycardia. All of the 10 catheterized patients had normal coronaries except for one with significant left anterior descending artery stenosis and another with a minor lesion. Symptomatic sustained ventricular tachycardia was found in two patients, one of whom required the implantation of an internal cardioverter-defibrillator.

Conclusions: Apical hypertrophic cardiomyopathy may develop morphologic and electrocardiographic changes with life-threatening arrhythmias necessitating close follow-up and treatment.

Background: The exact value of follow-up ultrasonogra­phy and computed tomography in the non-operative manage­ment of blunt splenic injuries is not yet defined. Although follow-up studies have been recommended to detect possible complications of the initial injury, evidence shows that routine follow-up CT scans usually do not affect management of these patients.

Objective: To determine whether follow-up imaging influences the management of patients with blunt splenic injury.

Methods: Between 1995 and 1999, 155 trauma patients were admitted with splenic trauma to a major trauma center. Excluded from the study were trauma patients with penetrating injuries, children, and those who underwent immediate laparotomy due to hemodynamic instability or associated injuries. The remaining trauma patients were managed conservatively. Splenic injury was suspected by focused abdominal sonography for trauma, upon admission, and confirmed by CT scan. The severity of splenic injury was graded from I to V. The clinical outcome was obtained from medical records.

Results: We identified 32 adult patients (27 males and 5 females) with blunt splenic injuries who were managed non-operatively. In two patients it was not successful, and splenectomy was performed because of hemodynamic dete­rioration. The remaining 30 stable patients were divided into two groups: those who had only the initial ultrasound and CT scan with no follow-up studies (n= 8), and those who under­went repeat follow-up ultrasound or CT scan studies (n = 22). The severity of injury was similar in both groups. In the second group follow-up studies showed normal spleens in 2 patients, improvement in 11, no change in 8, and deterioration in one. All patients in both groups were managed successfully with good clinical outcome.

Conclusion: In the present series the follow-up radiologi­cal studies did not affect patient management. Follow-up imaging can be omitted in clinically stable patients with blunt splenic trauma grade I-III.
 

Background: Smoking is the most important preventable cause of chronic disease in the western world. Many smokers want to quit, but have difficulty overcoming the addictive effect of nicotine.

Objectives: To assess the quitting rate of smokers who participated in smoking cessation groups and to characterize predictors of success or failure over a 1-3 year follow-up period.

Methods: We studied 89 participants in 7 groups. Questionnaires were completed at baseline and after a follow-up period of 1 to 3 years. Smoking cessation was determined by self-report and a carbon monoxide breath test.

Results: Of the 89 participants in the support groups 76 (85%) were located. An intention-to-treat analysis was done for these participants. At follow-up 25 (33%) were non-smokers. There was a 95% agreement rate between self-report of smoking status and CO breath analysis. There were no differences between quitters and non-quitters in education level, gender, age at initiation of smoking, previous quit attempts, extent of participation in group meetings, concern about gaining weight, Fagerstrom index, or the number of close friends or relatives who smoke. Belief in one's ability to quit, satisfaction with group meetings, and spouse support were significantly associated with success (P<0.01).

Conclusions: The quit rate was 33%. Self-report is a reliable method for assessing smoking status. Smokers' belief in their ability to quit must be reinforced. Spouse participation in some group meetings may be beneficial, as may the involvement of a dietician and an expert on exercise. Follow-up "booster" meetings may also help.

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CO= carbon monoxide

* In partial fulfilment of the requirements for an MD degree.