G. Blinder, J. Benhorin, D. Koukoui, Z. Roman and N. Hiller
Background: Multi-detector spiral computed tomography with retrospective electrocardiography-gated image reconstruction allows detailed anatomic imaging of the heart, great vessels and coronary arteries in a rapid, available and non-invasive mode.
Objectives: To investigate the spectrum of findings in 32 consecutive patients with chest pain who underwent CT coronary angiogram in order to determine the clinical situations that will benefit most from this new technique.
Methods: Thirty-two patients with chest pain were studied by MDCT[1] using 4 x 1 mm cross-sections, at 500 msec rotation with pitch 1–1.5, intravenous non-ionic contrast agent and a retrospectively ECG-gated reconstruction algorithm. The heart anatomy was evaluated using multi-planar reconstructions in the axial, long and short heart axes planes. Coronary arteries were evaluated using dedicated coronary software and the results were compared to those of the conventional coronary angiograms in 12 patients. The patients were divided into four groups according to the indication for the study: group A – patients with high probability for coronary disease; group B – patients after CCA[2] with undetermined diagnosis; group C – patients after cardiac surgery with possible anatomic derangement; and group D – symptomatic patients after coronary artery bypass graft, before considering conventional coronary angiography.
Results: Artifacts caused by coronary motion, heavy calcification and a lumen diameter smaller than 2 mm were the most frequent reasons for non-evaluable arteries. Assessment was satisfactory in 83% of all coronary segments. The overall sensitivity of 50% stenosis was 74% (85% for main vessels) with a specificity of 96%. Overall, the CTCA[3] results were critical for management in 18 patients.
Conclusions: Our preliminary experience suggests that CTCA is a reliable and promising technique for the detection of coronary artery stenosis as well as for a variety of additional cardiac and coronary structural abnormalities.
T. Gaspar, D. Dvir and N. Peled
Background: Computed tomography angiography enables non-invasive evaluation of the coronary arteries.
Objectives: To evaluate the accuracy of 16-slice multi-detector CT angiography in the diagnosis of coronary artery disease, and assess coronary bypass grafts and coronary anomalies.
Methods: We conducted a retrospective study of 223 patients who were examined at our medical center over a period of 2 years with a 16-slice CT angiography scanner and retrospective electrocardiographic gating.
Results: There were no significant complications, and good visualization of the coronary arteries was achieved in all but eight patients. A high correlation with the results of the invasive angiography was noted (sensitivity 85%, specificity 93%, negative predictive value 98%). Altogether, 131 bypass conduits were examined with excellent graft visualization. Several coronary anomalies were detected, as were significant extra-cardiac findings.
Conclusions: Multi-slice CT angiography is a reliable non-invasive diagnostic procedure for demonstration of the coronary arteries and bypass grafts. In the future it will probably replace part of the diagnostic invasive coronary angiography and, as a result, a large proportion of coronary angiography procedures will be therapeutic.
A. Leibovitz, Y. Barmoehl, D. Steinberg and R. Segal
Background: We previously reported on the high propensity of pathogenic oral flora in the oropharynx of nasogastric tube-fed patients, and subsequently showed biofilm formation on the NGTs[1] of these patients. There is a close relationship of biofilm and oropharyngeal colonization with pathogenic bacteria, aspiration pneumonia and antibiotic resistance.
Objectives: To investigate the time relation between the insertion of a new NGT and formation of the biofilm.
Methods: We examined sequential samples on NGTs that were forcibly pulled out by the patients themselves during any of the 7 days after insertion. Scanning electron micrography and confocal laser scanning microscopy were used for biofilm detection.
Results: Biofilm was identified on 60% of the 35 samples of day 1 and on all the samples of the following days, by both microscopic methods.
Conclusions: Biofilms form within a single day on most NGTs inserted for the feeding of elderly patients with dysphagia. Further research should be devoted to prevention of biofilm formation on NGTs.
A. Nadu, Y. Mor, J. Chen, M. Sofer, J. Golomb and J. Ramon
Background: Data during the last decade show that laparoscopic nephrectomy is becoming an accepted and advantageous minimally invasive alternative to the open procedure.
Objective: To evaluate the efficacy, safety and reproducibility of laparoscopic nephrectomy in a series of 110 consecutive procedures.
Methods: A total of 110 patients underwent laparoscopic nephrectomy in our institution during the last 3 years. Their data were entered into a database and analyzed, including age, gender, indications for surgery, operative time, blood loss, intraoperative complications, conversion rates, and postoperative complications (defined as complications occurring up to 1 month after surgery). Histologic results and outpatient follow-up were also recorded.
Results: Mean age at surgery was 63 years (range 21–89 years). The indications for surgery included solid renal masses in 64 cases, non-functioning kidneys in 35, and collecting system or ureteral tumors in 11; and the procedures performed were radical nephrectomy, simple nephrectomy, or nephroureterectomy, respectively. The mean operative time was 125 minutes (range 70–310 minutes). Intraoperative complications were recorded in eight cases (7.3%), including vascular injuries of the renal artery in two, and of the renal vein, inferior vena cava and right adrenal vein in one case each. Injury of the large bowel and splenic hylus was recorded in one case and malfunction of the vascular endoGIA stapler leading to severe bleeding in one case. Nine cases were converted to open surgery (8.2%), four of them urgently due to intraoperative complications, while in another five cases conversions were elective following poor progression of the laparoscopic procedure. Comparison of the complication rate at follow-up between the initial 50 and the last 60 patients revealed no change. The conversion rate dropped significantly along the learning curve with 7 cases converted among the initial 50 patients, versus 2 in the last 60. There was no perioperative mortality. In two cases we recorded major postoperative complications, including pneumothorax treated by insertion of a thoracic drain and incarcerated inguinal hernia treated by surgery, while minor complications were seen in five patients. Histologic examination showed renal cell carcinoma pT1-T3a in 62 patients, oncocytoma in 5, transitional cell carcinoma T1G2-T3G3N1 in 10, renal sarcoma in 1, metastasis from lung tumor in 1, and end-stage kidney in the remainder. Negative margins were obtained in all cases.
Conclusions: Laparoscopic nephrectomy may be currently considered a routine, safe and effective procedure associated with minimal morbidity. The conversion rate seemed to drop significantly after 50 cases. In view of the inherent benefits for patients, in terms of reduced pain level, faster recovery and improved cosmetic results, the laparoscopic approach has become the standard approach for nephrectomy in our institution.
S.D. Duek, M.M. Krausz and D.D. Hershko
Background: Transanal endoscopic microsurgery has recently gained acceptance as an alternative minimally invasive surgical technique for the curative management of large rectal adenomas and selected early rectal carcinomas.
Objectives: To analyze our 8 year experience using TEM[1] for the management of rectal cancer.
Methods: Local resection by TEM was performed in patients with benign tumors and early rectal cancer. In addition, selected patients with T2 and T3 rectal cancers who were either medically unfit or unwilling to undergo radical surgery were also treated with this modality. Radical surgery was offered to all patients with incomplete tumor excision by TEM.
Results: Overall, 116 TEM operations for rectal tumors were carried out between 1995 and 2003, including 74 patients with rectal adenomas and 42 patients with rectal carcinomas. Twenty-five patients had T1 tumors that were all successfully removed, with clear tumor margins, by TEM. Fourteen patients had T2 cancer and 3 of them (21%) required additional radical surgery due to incomplete excision. Local recurrence was observed in one patient with T2 cancer. There was no mortality. Major surgery, or radiotherapy-related complications requiring additional surgical intervention was needed in five patients with T2 cancer.
Conclusions: Local excision by TEM is a safe surgical procedure and should be offered to highly selected patients with early rectal cancer.
E. Evron, L. Barzily, E. Rakowsky, N. Ben-Baruch, J. Sulkes, S. Rizel and E. Fenig
Background: Post-mastectomy loco-regional radiation to the chest wall and draining lymphatics, combined with adjuvant chemotherapy and hormonal therapy, significantly improve survival in patients with node-positive breast cancer. However, the actual benefit of post-mastectomy radiotherapy and the desired extent of treatment are still debatable.
Objectives: To examine the effect of postoperative loco-regional radiotherapy on local and regional recurrence and survival in breast cancer patients with four or more involved lymph nodes or extracapsular tumor extension.
Methods: This controlled clinical trial included 258 breast cancer patients with four or more involved nodes or ECE[1]. Eighty-nine patients in the control group had modified radical mastectomy and received adjuvant chemotherapy with melphalan and 5FU, but no radiation therapy. The 169 patients in the study group (87 with MRM[2] and 82 with lumpectomy and axillary dissection) received various adjuvant chemotherapy regimes and radiation therapy to the chest wall/breast, supraclavicular region and full axilla.
Results: With an average follow-up of more than 5 years, loco-regional radiation significantly reduced local and regional disease recurrence. The median disease-free survival was significantly longer in radiated patients (59.2 months and 63.3 months in the MRM and L+AXLND[3] groups, respectively, vs. 28.4 months in the control group; P < 0.01). There was no difference in the rate of systemic recurrence and overall survival. The median overall survival was 71.2 and 67.5 months in the study groups (MRM and L+AXLND, respectively) and 70.5 months in the control group (P = 0.856).
Conclusions: Radiotherapy to the breast/chest wall and to the draining lymphatics, in addition to surgery and adjuvant therapy, significantly reduced the risk of local and regional recurrence in high risk breast cancer patients with four or more involved lymph nodes or ECE.
S. Codish, S. Dobrovinsky, M. Abu Shakra, D. Flusser and S. Sukenik
Background: The efficacy of spa therapy in ankylosing spondylitis has not been investigated extensively.
Objective: To study the efficacy of balneotherapy and climatic therapy (climatotherapy) at the Dead Sea area in patients with ankylosing spondylitis.
Methods: In a single-blind randomized controlled study, 28 patients suffering from ankylosing spondylitis were allocated into two groups of 14 patients each. The first group (the combined treatment group) received balneotherapy (mud packs and sulfur pool) and exposure to the unique climatic conditions of the Dead Sea. The second group (the climatotherapy group) used the fresh water pool and experienced the same climatic conditions. The duration of treatment was 2 weeks and the follow-up period 3 months.
Results: For both patient groups a significant improvement was found in the outcome measures: Bath AS[1] Disease Activity Index (P = 0.002), Visual Analog Scale for pain (P = 0.002) and VAS[2] for spinal movement (P = 0.011). The variability was explained by the effect of time (within group effect) rather than the type of treatment (within group effect). Quality of life, assessed by the SF-36 questionnaire, was very low prior to the study, but improved in terms of pain amelioration in the combined treatment group.
Conclusions: Climatotherapy at the Dead Sea area can improve the condition of patients suffering from long-standing ankylosing spondylitis.
L. Pollak, M. Kushnir, Y. Shpirer, Y. Zomer and S. Flechter
Background: Benign paroxysmal positional vertigo is a common and treatable vestibular disorder characterized by attacks of positional vertigo. Although elderly patients often complain about unsteadiness, the symptom of positional vertigo is seldom reported. Several studies on BPPV[1] in the elderly reveal a low success rate in the treatment of this entity.
Objectives: To assess the clinical characteristics and treatment outcome of BPPV in elderly patients and to compare them with those of the general population treated at our dizziness clinic.
Methods: We reviewed the medical records of 23 patients above age 75 who were treated at our dizziness clinic for BPPV during the years 1998–2004. Their clinical data, BPPV characteristics and treatment outcome were compared with the data of 30 consecutive BPPV patients who represented the general population.
Results: No differences in gender distribution, duration of BPPV, treatment responsiveness or recurrence rate were found between elderly patients as compared to the general population. The duration of the last attack of positional vertigo was found to be longer in the elderly, probably due to the delay in recognition of symptoms and accessibility of a dizziness clinic.
Conclusions: Our study shows that BPPV characteristics and treatment effectiveness, as measured by negative Dix-Hallpike maneuver, are not age-dependent and there is no need for a special approach or cautiousness in prognosis prediction. It is important to search actively for this condition since treatment leads to amelioration of unsteadiness and improved well-being in these patients.
[1] BPPV = benign paroxysmal positional vertigo