E. Glassberg, D. Neufeld, I. Shwartz, I. Haas, P. Shmulewsky, A. Benov and H. Paran
Background: Laparoscopic repair of giant diaphragmatic hernias (GDH) can be challenging, especially when partial or complete volvulus of the herniated stomach is encountered.
Objectives: To review our experience with laparoscopic repair of GDH, emphasizing preoperative investigation, technical aspects, and outcome.
Methods: We conducted a retrospective review of patients operated on for GDH who were diagnosed when at least half the stomach was found in the mediastinum at surgery. Technical aspects and surgical outcomes were evaluated.
Results: Fifty patients underwent laparoscopic GDH repair during an 8 year period. Four patients admitted with acute symptomatic volvulus of the stomach were initially treated by endoscopic decompression followed by surgery during the same admission. Two cases were converted to open surgery. Initial surgery was successful in 45 patients; 3 had an immediate recurrence, 1 was reoperated for dysphagia during the same admission, and 1 had a mediastinal abscess. During long-term follow-up, six patients required reoperation for recurrent hernias. Another four patients had asymptomatic partial herniation of the stomach. The main reason for failure was incomplete reduction of the hernia sac, especially the posterior component. No correlation was found between the type of repair and surgical failure. Most patients who did not undergo an anti-reflux procedure had postoperative reflux unrelated to their preoperative workup.
Conclusions: Laparoscopic repair of GDH is challenging, but practical and safe. It should be the treatment of choice for this potentially life-threatening condition. Careful attention to pitfalls, such as the posterior element of the sac, and routine performance of an anti-reflux procedure are crucial.
S. Billan, O. Kaidar-Person, F. Atrash, I. Doweck, N. Haim, A. Kuten and O. Ronen
Background: The role of induction chemotherapy in advanced squamous cell carcinoma of the head and neck (SCCHN) is under constant debate. Surgery, radiotherapy, chemotherapy, and targeted therapies are part of the treatment strategy in these patients, but their sequence remains to be defined.
Objectives: To evaluate the feasibility of induction chemotherapy with docetaxel-cisplatin-5-flurouracil (TPF) followed by external beam radiotherapy (EBRT) with concomitant chemotherapy (CRT) or cetuximab (ERT) in the treatment of patients with advanced SCCHN.
Methods: We reviewed the data of all patients with advanced SCCHN, stage III and IV, treated in 2007–2010. Tolerability was assessed and scored according to the proportion of patients completing the planned study protocol. Toxicity was scored using the U.S. National Cancer Institute Common Toxicity Criteria (version 4) for classification of adverse events.
Results: The study included 53 patients. TPF was initiated at a reduced dose in 13 patients (25%). Twenty-two patients (41.5%) received primary prophylaxis with granulocyte colony-stimulating factor (GCSF) and 42 (77%) completed treatment according to schedule. During the induction phase one patient (2%) died and 24 (45%) had one or more grade 3-4 complications. The number of patients who developed neutropenia was lower in the group that received primary GCSF prophylaxis. Secondary dose reductions were required in 21% of the patients.
Conclusions: Induction TPF was associated with grade 3-4 toxicity. Prophylaxis with GCSF should be part of the treatment regimen.
J.Y. Streifler, G. Raphaeli, N.M. Bornstein, N. Molshatzki and D. Tanne
Background: Patients with transient ischemic attack (TIA) at a high risk of stroke can be identified and should be managed urgently.
Objectives: To investigate whether recognized recommendations are being implemented in Israel.
Methods: An Israeli nationwide registry on patients admitted with stroke and TIA was conducted in all acute care hospitals (NASIS registry) within 2 successive months during 2004, 2007 and 2010. A revised ABCD2 score was applied retrospectively. Patients with TIA were divided into a low risk group (LRG, 0–3 points) and a high risk group (HRG, 4–6 points) and were compared to patients with minor ischemic strokes (MIS, NIHSS score ≤ 5 points).
Results: A total of 3336 patients were included (1023 with TIA: LRG 484, HRG 539, and MIS 2313). LRG patients were younger and had lower rates of most traditional risk factors as compared with HRG and MIS patients. Brain imaging was performed in almost all the patients. Ancillary tests (vascular and cardiac) were overall underused, yet were performed more in LRG (53.2% and 26.9% respectively) than in HRG patients (41.6%, 18.9%). Between periods there was no change in usage of ancillary tests for the LRG and a modest increase in both HRG and MIS patients. For performance of vascular investigations overall, the odds ratio was 1.69 (95% confidence interval 1.42–2.00) comparing 2010 with 2004, but 0.7 (95% CI 0.5–0.9) comparing HRG with LRG. Between periods an increase in statin usage was observed in all groups (OR 2.69, 95% CI 2.25–3.21) but was more marked in MIS patients (OR 3.06, 95% CI 2.47–3.8).
Conclusions: The approach to TIA risk stratification and management in Israeli hospitals does not follow standards set by current guidelines. Standardized protocols for TIA should be used to assure effective management.
E. Heldenberg and A. Bass
M. Haifler and K. Stav
Dysfunctional voiding is characterized by an intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the periurethral striated or levator muscles during voiding in neurologically normal women (International Continence Society definition). Due to the variable etiology, the diagnosis and treatment of DV is problematic. Frequently, the diagnosis is done at a late stage mainly due to non-specific symptoms and lack of awareness. The objectives of treatment are to normalize micturition patterns and prevent complications such as renal failure and recurrent infections. Treatment should be started as early as possible and a multidisciplinary approach is beneficial.
A. Shturman, M. Gellerman and S. Atar
S. Perlman, O. Paz, Z. Hagay, S. Shimoni, A. Caspi and S. Goland
G. Shlomai, A. Belkin, O. Goitein, O. Portnoy and E. Grossman
E. Calif, S. Stahl and J. Hakim Jeries