Israel Medical Association Journal

Objectives: To assess factors related to the learning curve of laparoscopic colorectal surgery, such as the number of operations performed, the type of procedures, major complications, and oncologic resections.

Methods: We evaluated the data of our first 100 elective laparoscopic colorectal operations performed during a 2 year period and compared the first 50 cases with the following 50.

Results: The mean age of the study population was 66 years and 49% were males. Indications included cancer, polyps, diverticular disease, Crohn’s disease, and others, in 50%, 23%, 13%, 7% and 7% respectively. Mean operative time was 170 minutes. One patient died (massive pulmonary embolism). Significant surgical complications occurred in 10 patients (10%). Hospital stay averaged 8 days. Comparison of the first 50 procedures with the next 50 revealed a significant decrease in major surgical complications (20% vs. 0%). Mean operative time decreased from 180 to 160 minutes and hospital stay from 8.6 to 7.2 days. There was no difference in conversion rate and mean number of harvested nodes in both groups. Residents performed 8% of the operations in the first 50 cases compared with 20% in the second 50 cases. Right colectomies had shorter operative times and fewer conversions.

Conclusions: There was a significant decrease in major complications after the first 50 laparoscopic colorectal procedures. Adequate oncologic resections may be achieved early in the learning curve. Right colectomies are less difficult to perform and are recommended as initial procedures.

Objectives: To evaluate the safety and efficacy of external counter-pulsation therapy in heart failure patients.

Methods: Fifteen symptomatic heart failure patients (subsequent to optimal medical and device therapy) underwent 35 hourly sessions of ECPT[1] over a 7 week period. Before and after each ECPT session we performed pro-B-type natriuretic peptide and brachial artery function studies, administered a quality of life questionnaire, and assessed exercise tolerance and functional class.

Results: Baseline left ventricular ejection fraction was 28.1 ± 5.8%. ECPT was safe and well tolerated and resulted in a reduction in pro-BNP[2] levels (from 2245 ± 2149 pcg/ml to 1558 ± 1206 pcg/ml, P = 0.022). Exercise duration (Naughton protocol) improved (from 720 ± 389 to 893 ± 436 seconds, P = 0.0001), along with functional class (2.63 ± 0.6 vs. 1.93 ± 0.7, P = 0.023) and quality of life scores (54 ± 22 vs. 67 ± 23, P = 0.001). Nitroglycerine-mediated brachial vasodilatation increased (11.5 ± 7.3% vs. 15.6 ± 5.2%, P =0.049), as did brachial flow-mediated dilation (8.35 ± 6.0% vs. 11.37 ± 4.9%, P = 0.09).

Conclusions: ECPT is safe for symptomatic heart failure patients and is associated with functional and neurohormonal improvement. Larger long-term randomized studies with a control arm are needed to confirm these initial encouraging observations.

Objectives: To determine whether this policy is still applicable. 

Methods: We performed prospective sampling and follow-up of women admitted for labor and delivery between February 2002 and July 2002. Vaginal and rectal cultures were obtained before the first pelvic examination. GBS isolation was performed using selective broth medium, and identified by latex agglutination and serotyping. Demographic data were collected by means of a standardized questionnaire. Data on the newborns were collected throughout 2002.

Results: Of the 629 sampled women, 86 had a positive culture and a carrier rate of 13.7%. A borderline significantly higher carriage rate was observed among mothers of North American origin (21% vs. 13.1%, P = 0.048), and a higher attack rate in their infants (3.8/1000 compared with 0.5/1000 live births in our general maternal population, P = 0.002). Eight newborns had early-onset neonatal GBS sepsis (a rate of 0.8/1000 live births), but none of them benefited from intrapartum antibiotic prophylaxis.

Conclusions: An increased neonatal disease rate was observed in a population with a higher colonization rate than previously seen. In lieu of the higher carrier rates, we now recommend routine prenatal screening for GBS in our perinatal population.

Contamination of food with streptococci could present with unusual outbreaks that may be difficult to recognize in the early stages. This is demonstrated in a large food-borne outbreak of streptococcal pharyngitis that occurred in 2003 in a factory in Israel. The outbreak was reported to the public health services on July 2 and an epidemiologic investigation was initiated. Cases and controls were interviewed and throat swabs taken. An estimated 212 cases occurred within the first 4 days, the peak occurring on the second day. There was a wave of secondary cases during an additional 11 days. The early signs were of a respiratory illness including sore throat, weakness and fever, with high absenteeism rates suggesting a respiratory illness. As part of a case-control study, cases and controls were interviewed and throat swabs taken. Illness was significantly associated with consumption of egg-mayonnaise salad (odds ratio 4.2, 95% confidence interval 1.4–12.6), suggesting an incubation period of 12–96 hours. The initial respiratory signs of food-borne streptococcal pharyngitis outbreaks could delay the identification of the vehicle of transmission. This could be particularly problematic in the event of deliberate contamination.

Background: The rate of trauma in the elderly is growing.

Objectives: To evaluate the characteristics of non-hip fracture-associated trauma in elderly patients at a level I trauma center.

Methods: The study database of this retrospective cohort study was the trauma registry of a level I trauma center. Trauma patients admitted from January 2001 to December 2003 were stratified into different age groups. Patients with the diagnosis of hip fracture were excluded.

Results: The study group comprised 7629 patients. The non-hip fracture elderly group consisted of 1067 patients, 63.3% women and 36.7% men. The predominant mechanism of injury was falls (70.5%) and most of the injuries were blunt (94.1%). Injury Severity Score was found to increase significantly with age. The average mortality rate among the elderly was 6.1%. Age, ISS[1], Glasgow Coma Score on admission, and systolic blood pressure on admission were found to be independent predictors of mortality.

Conclusions: Falls remain the predominant cause of injury in the elderly. Since risk factors for mortality can be identified, an effective community prevention program can help combat the future expected increase in morbidity and mortality associated with trauma in the elderly.

Background: The degree of left ventricular dysfunction determines the prognostic outcome of patients with acute myocardial infarction.

Objectives: To define the clinical, angiographic and procedural variables related to LV[1][1] dysfunction in patients with  with anterior wall AMI[1][2] referred for primary percutaneous coronary intervention.

Methods: The sample included 168 patients treated by primary PCI[1][3] for first anterior wall AMI. Clinical, demographic and medical data were collected prospectively into a computerized registry, and clinical outcome (death, reinfarction, major cardiovascular event) were evaluated during hospitalization and 30 days after discharge. Patients were divided into three groups by degree of LV dysfunction (mild, moderate, severe) and compared for clinical, angiographic and procedural variables.

Results: LV dysfunction was associated with pre-PCI renal failure (serum creatinine > 1.4 mg/dl), peripheral vascular disease, high peak creatine kinase level, longer door to balloon time, low TIMI flow grade before and after PCI, and use of an intraaortic balloon pump. On multivariate analysis adjusted for baseline differences, peak creatine kinase level (r = 0.3, P = 0.0001) and door to needle time (r = 0.2, P = 0.008) were the most significant independent predictors of moderate or severe LV dysfunction after anterior AMI.

Conclusion: Abnormal LV function after first anterior AMI can be predicted by door to balloon time and the size of the infarction as assessed by creatine kinase levels. Major efforts should be made to decrease the time to myocardial reperfusion.

[1][1] LV = left ventricular

[1][2] AMI = acute myocardial infarction

[1][3] PCI = percutaneous coronary intervention 

Objectives: To report a 14 year experience of RFA[2] of the slow pathway in patients with AVNRT treated in our laboratory.

Methods: A total of 901 consecutive patients (aged 9–92, mean 50.8 ± 18.2 years) underwent RFA of the slow pathway. All patients had sustained AVNRT induced with or without intravenous administration of isoproterenol. A standard electrophysiologic method with three diagnostic and one ablation catheter was used in 317 patients (35.2%); in the remaining 584 patients (64.8%), only two electrode catheters (one diagnostic, one ablation) were used ("two-catheter approach").

Results: Catheter ablation of the slow pathway abolished AVNRT induction in 877 patients (97.3%). In 14 patients (1.6%) the procedure was discontinued while in 10 (1.1%) the procedure failed. In 864 patients (95.9%) there were no complications. Transient or permanent AV block occurred during the procedure in 31 patients (3.4%), of whom 8 (0.9%) eventually required pacemaker insertion (n=7) or upgrade of a previously implanted VVI pacemaker (n=1) during the month following the procedure. The number of catheters used did not significantly affect the rate of results or complications of the ablation procedure. The success and complication rates remained stable over the years, although a significant trend for increased age and associated heart disease was observed during the study period.

Conclusions: The results of this single-center large study, which included patients with a wide age range, showed results similar to those of previous studies. The use of a "two-catheter approach" (one diagnostic and one ablation) was as effective and safe as a multi-catheter approach.