תוצאת חיפוש

רונן ש' גולד, יוסף ב' לסינג, דוד פאוזנר ודוד גורדון

היחידה לאורגינקולוגיה וריצפת האגן, ביה"ח ליולדות ליס, מרכז רפואי תל-אביב, הפקולטה לרפואה, אוניברסיטת תל-אביב

התהוות נצור בין שלפוחית השתן והלדן (נשש"ל) גורמת להשפעות קשות הן על התיפקוד הגופני והן על מצבי הנפשי של החולה. במדינות מתפתחות מהווה נשש"ל סיבוך שכיח של טראומה מיילדותית. במדינות אלו, מתלווה לבעיה זו גם בעיה חברתית קשה. במדינות מפותחות נשש"ל הוא נדיר יותר ורוב החולות לוקות בו עקב ניתוח גינקולוגי. אין ספק, כי נשש"ל יכול להיגרם גם בידיו של מנתח מוכשר ביותר ובעל ניסיון רב. מרגוליס טוען, כי כל שדרוש הוא מספיק זמן ומספיק ניתוחים כדי שנשש"ל ייגרם על ידי כל מנתח. למרות שנשש"ל מוכר עוד מתקופות קדומות, הרי שניתוח מוצלח דווח לראשונה רק בשנת 1952: ג'ימס מירון סייס דיווח על סגירת נשש"ל בגישה לדנית באמצעות חוטי כסף. הטיפול העדכני בנשש"ל החל רק באמצע המאה ה-20, תחילה בגישה ביטנית ובהמשך בגישה לדנית. למרות ההתקדמות בשטח זה, בחירת הדרך הטוב ביותר לטיפול וקביעת התיזמון לפעולה נותרו גם היום בגדר אתגר רפואי.

Primary Gastrointestinal Stromal Tumors

Y. Wiener¹, R. Gold¹, S. Zehavy², J. Sandbank², A. Halevy¹

¹Dept. of General Surgery and Dept. of Pathology, ²Assaf Harofeh Medical Center, Israel

Stromal tumors of the GI tract are rare. In the retrospective and prospective study we investigated the relationship between tumor symptomatology, tumor grade and prognostic factors. During the period May 1993 - September 1999, 11 female and 13 male patients with a mean age of 62 (range-29-81) years were operated for primary gastrointestinal stomal tumors (GIST) in our department. Observed signs and symptoms were: GI bleeding (65%), abdominal pain (45%), abdominal mass (15%) and weakness (5%). In 4 patients tumor was an incidental finding during investigation or operation for another tumor. Tumor location (in decreasing order) was: stomach (15), small bowel (SB, 6), esophagus (1), duodenum (1) and colon (1). Preoperative biopsy or FNA were diagnostic in less than 50% of the cases. Operative procedures included wedge resection (8 patients), resection of segment of bowel (10) and extended resection (6), of diaphragm, SB, colon, bladder, kidney and liver. The mean tumor size was 7.8 (range-0.9-22) cm. Four tumors were graded as benign, 8 of indeterminate malignant potential and 12 malignant.

Conclusion: The main presentation of GIST is acute GI bleeding. Endoscopy is most effective for studying proximal tumors, and CT should be used to identify distal GI tract tumors. Tumor size or malignancy were not necessarily predictive of GI bleeding. When invasive to adjacent organs is present, wide excision should be contemplated as long-term survival can be achieved.

דניאל זיידמן, מוטי גולדנברג

מח' נשים ויולדות, מרכז רפואי חיים שיבא, תל-השומר והפקולטה לרפואה סאקלר, אוניברסיטת תל-אביב

כירורגיה לאפארוסקופית מקובלת כיום כגישה בעלת יתרונות מוכחים לביצוע מרבית הניתוחים הגינקולוגיים. עם זאת, מגבלות טכניות עדיין מקשות על מנתחים רבים לאמץ את השיטה הלאפארוסקופית בבואם לבצע ניתוחים מורכבים יותר, כמו כריתת שרירומות או כריתת רחם. אחת הבעיות העיקריות המקשות על ביצוע ניתוחים באמצעות לאפארוסקופיה היא הצורך ביצירת שדה ניתוח מספק בחלל הבטן, השיטה הנפוצה ביותר להרמת דופן הבטן ודחיקת המעי היא ניפוח הבטן עם גאז פחמן דו-חמצני (CO₂), כלומר, יצירת אוורת הצפק. שיטה זו יוצרת קשיים עקב הצורך למנוע דליפת גאז מחלל הבטן במהלך הניתוח. הדבר מחייב עבודה עם כלי ניתוח מיוחדים המוחדרים דרך טרוקרים עם שסתומים חד-כיווניים, ומקשה על פינוי ריקמה מחלל הבטן והאגן וביצוע תפירה כירורגית. בנוסף, פתיחת כיפת הלדן בעת ניתוחים גינקולוגיים, כמו כריתת רחם, מובילה לדליפה מהירה של הגאז מחלל הבטן.

ולדימיר שץ

כרמיאל

הפחתת מאגרים קוגניטיביים במחלת אלצהיימר (מ"א) נובעת מדילדול מוחי, אולם קיים היבט אחר של התופעה המתבטא בכך, שהמאגרים מופחתים עשרות שנים לפני התהוות המחלה. במחקרים אחדים, לא נמצא קשר בין רמת השכלה ובין שיעור וקצב החמרת השיטיון ככל ובמ"א בפרט. אולם ברוב הפירסומים, כולל רב-מרכזיים, נמצא שרמת השכלה נמוכה מעלה את שיעור קצב הירידה הקוגניטיבית לפני התחלתה ואת קצב החמרתה של מ"א. בסקירה זו סוכם מידע בסוגיה זו.

התפיסה המקובלת היא, כי חיתוך דופן אלקטיבי אשר נעשה ללא הוריה רפואית הוא פעולה פסולה. בעשור האחרון למאה ה-20, הובעו דעות שחלקו על תפיסה זו והתעורר ויכוח לגבי מקומה של הלידה הלדנית במאה ה- 21. הוויכוח אשר זכה לתהודה תקשורתית רבה החל בבריטניה והתעורר אף בישראל, בה שיעור חיתוכי הדופן עולה בהתמדה. עפ"י הנתונים שנאספו ע"י יו"ר החוג לרפואה סב-לידתית והוצגו בכינוס השנתי האחרון (7 ביולי 2000), היה השיעור הממוצע של חיתוכי הדופן בשנת 1999 כדי 14.6% מכלל הלידות בישראל, פי שלושה מהשיעור בשנת 1977 (5.5%) ובשליש יותר לעומת השיעור חמש שנים קודם לכן (11.3%). בסקירה של בן-הרוש וחב' (בגיליון זה), נדונה השאלה של ניהול לידה פעיל בתקופתנו. לאור הוויכוח לגבי חיתוך-דופן עפ"י בקשת היולדת (cesarean section upon maternal request) נראית שאלה זו לכאורה ארכאית. לפיכך, בצד ניהול לידה פעיל, יש להכיר את הוויכוח לגבי אופייה של הלידה הלדנית במאה ה- 21.

Diagnostic Laparoscopy for Abdominal Lymphoma

D. Lev-Chelouche, D. Margal, J.M. Klausner, A. Szold

Dept. of Surgery B, Tel Aviv-Sourasky Medical Center (Affiliated with Sackler Medical Faculty, Tel Aviv University)

Imaging-guided (CT/US) percutaneous biopsy has significantly improved diagnosis of intra-abdominal lymphoma. However, in many cases the tissue retrieved may be inadequate for specialized studies such as immunophenotyping or cytogenetic analysis that may be required for a complete analysis of lymphoma or determination of therapy.

The success of diagnostic laparoscopy in the diagnosis and staging of gastrointestinal malignancies suggests that it could be used for intra-abdominal lymphomas as well. We describe our experience in 15 patients with suspected lymphoma who underwent diagnostic laparoscopy during 1995-98.

Preoperative investigation performed in all included percutaneous FNA in 9 without conclusive diagnosis. Laparoscopy was diagnostic for lymphoma in 14 (93%) while in 1 there was a false negative result due to sampling error and the lymphoma was only diagnosed at a second laparoscopy.

There was no mortality nor any major complication. Average hospital stay was 2 days and patients were then referred for further oncological treatment. Our experience shows that diagnostic laparoscopy is a safe and efficient tool and without major complications in diagnosing abdominal lymphoma.
 

Long-Term Sequelae of Malignant Tumors in Childhood

N. M. Peretz, H. Goldberg, A. Kuten, I. Meller, E. Krivoi, A. Lorber, L. Bentur, A. Lightman, V. Gorenberg, M. Ben Arush-Weyl

Pediatric Hematology-Oncology Dept., Oncology Center, Pediatric Cardiology Unit, Pulmonology and Gynecology Depts., and Pediatric Endocrinology Unit; Rambam Medical Center and Technion-Israel Institute of Technology, Haifa; and Orthopedic-Oncology Unit, Tel Aviv-Sourasky Medical Center and Tel Aviv University

110 children with malignant diseases (leukemia excepted) who survived 5-20 years (median 9) post-therapy were followed (1996-1998). Median age during follow-up was 15 years (range 5-23). The most common malignancies were brain tumors, lymphoma, retinoblastoma and Wilm's tumor.

The 174 late side-effects included endocrine disorders (19%), cognitive impairment (14%), orthopedic dysfunction (12%), alopecia (12%), dental damage (11%), psychological (8%) and neurological (8%) disturbances, and azoospermia or amenorrhea (5%). There was no cardiac or renal damage and no second malignancy.

29% of side-effects were severe. There was significant reduction in quality of life in 54 (49%), in 27 of whom it was severe enough to require psychological intervention. Treatment of brain tumor caused 98 late side-effects in 28 patients (sequelae-to-patient ratio [SPR] 3.3). Most cognitive, endocrine and neurological disorders, and most cases of alopecia, dental and psychological difficulties were in these patients. There were frequent late complications in those treated for retinoblastoma (SPR 1.8), and bone or soft tissue sarcomas (SPR 0.8). Those treated for Wilm's tumor had few side-effects (SPR 0.4).

Late side effects were most frequent after radiation, reaching as high as SPR 2.4. It averaged only 0.5 in those treated with chemotherapy alone or in combination with surgery.

Reduction of late side-effects in these patients requires using less toxic modalities, as long as cure rate is not compromised. When considering secondary strategies, screening for early detection of late complications would enable immediate solutions, such as hormonal replacement or providing compensating skills for post-treatment disability.
 

Dermatitis from Contact with Agave Americana

Haim Golan, Marina Landau, Ilan Goldberg, Sara Brenner

Dermatology Dept., Tel Aviv-Sourasky Medical Center

Various plants induce dermatitis in man. There have been only a few published cases of contact dermatitis caused by Agave americana (AA).

We report intentional exposure to AA in a soldier seeking sick leave, and review our previously reported cases. Treatment with oral antihistamines and topical saline compresses resulted in subsidence of the systemic symptoms within 24h and regression of cutaneous manifestations in 7-10 days.

Physicians should be alert to the possibility of self-inflicted contact dermatitis induced by exposure to plants, especially to A. americana. Systemic signs may accompany the cutaneous lesions.

Secondary Bone Grafting in Cleft Lip and Palate

M. Peled, D. Aisenbud, D. Goldstein, A. Rachmiel, D. Laufer

Maxillofacial and Oral Surgery Dept. and Cleft-Palate Clinic, Rambam Medical Center; and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Results of reconstruction of residual alveolar bone defects in 52 patients operated between 1990-1998 were evaluated clinically and radiographically in a retrospective study.

Ages ranged between 9-37; 30 were males. The donor site of bone grafts in all was particulate cancellous marrow from the anterior iliac crest. 32 had unilateral clefts and 20 bilateral. Total cleft sites treated was 72.

Best results were achieved when bone grafting was carried out prior to the eruption of the canine tooth. The cleft space was closed and oro-nasal fistulas were eliminated in 42 (80%). Success rates in unilateral and bilateral cases were significantly different.

Acute Lymphoblastic Leukemia in Adults Treated with German Multicenter Study Group Protocols

G. Goldstein, O. Shpilberg, P. Raanani, A. Chetrit, I. Ben-Bassat

Institutes of Hematology and of Clinical Epidemiology, Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University

Acute lymphoblastic leukemia (ALL) is a malignant disease whose incidence is relatively low among adults, unlike in children. Adults with ALL have a lower rate of long-term disease-free survival. During the last 20 years, a German multicenter group has shown that their protocol have achieved good results in adult ALL.

We reviewed the medical records of 35 ALL patients, aged 19-63 years, whome we treated with these protocol (1988-1997). The remission rate was 94%. At a median follow-up of 46 months the 2-year overall survival was 54% and the disease-free survival was 94%. Although 2 patients died of bone marrow transplant complications, no death was directly associated with drug toxicity. The main grade 3 or 4 side effects (WHO classification) were neutropenia (91%), thrombocytopenia (71%) and anemia (71%).

With there protocols we achieved high overall and disease-free survival rates, especially in comparison with other reports. Despite the high rate of severe treatment toxicity, there were no fatalities directly related to treatment. These results emphasize the need to concentrate treatment of adult ALL patients in large medical centers with expertise in the use of the complicated treatment protocols required.

Tuberculous Meningitis in Review

Mozes Toledo, Y. Skurnik, A. Razabek, Z. Stoeger

Medical Dept. B, Kaplan Medical Center, Rehovot, (Affiliated with Hebrew University-Hadassah Medical School, Jerusalem)

Tuberculosis meningitis is one of the most dangerous forms of tuberculosis (TB). Due to large waves of immigration, the incidence of TB in Israel has increased in recent years, as has that of TB meningitis. Due to its high mortality, rapid diagnosis of TB meningitis is of paramount importance.

We present a patient admitted with a acute febrile disease which was subsequently diagnosed as TB meningitis.

Laparoscopic Approach in Treating Hepatic Cysts 

P. Schachter, V. Sorin, M. Shimonov, A. Rosen, A. Czerniak

Dept. of Surgery A, Wolfson Medical Center, Holon

Solitary and multiple hepatic cysts are now more commonly found because of advances in imaging techniques. Most hepatic cysts are asymptomatic, but when they do cause symptoms they require surgical intervention. The advent of laparoscopy and of laparoscopic ultrasonography allow comprehensive evaluation and treatment of the cysts.

12 patients with hepatic cysts were treated laparoscopically. 8 with single cysts underwent successful subtotal cyst resection without signs of recurrence (up to 20 years of follow-up). 4 with polycystic liver disease underwent sub-total resection of superficial cysts. Deep cysts were unroofed and drained under laparoscopic ultrasound guidance. In this group, 1 experienced recurrence of symptoms and required partial hepatectomy of the involved segment. In another, a connection between a deep cyst and bile ducts was demonstrated and cystojejunostomy was performed.

The laparoscopic approach in the management of patients with liver cysts is effective and safe, and we recommend it as the procedure of choice for single hepatic cysts. In polycystic liver disease the procedure is much less successful.

Early Detection of Glaucoma by a Mobile Unit

S. Kurtz, M. Goldenfeld, S. Melamed

Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer

Glaucoma, the third leading cause of blindness in the western world, is characterized by painless, gradual loss of visual fields which may lead to severe visual impairment or even blindness. In 4 years of operation of a mobile glaucoma unit for screening and early diagnosis of glaucoma, 10,037 subjects aged 18-95 years were screened (4504 women, 45%); 55% were under 50 years (Graph 1).

Ocular hypertension was diagnosed in 8.0%; primary open angle glaucoma (POAG) in 0.8%, with 2/3 already under treatment, the rest newly diagnosed. Pseudo-exfoliative glaucoma was diagnosed in 0.2%; only 2 cases had closed angle glaucoma; 91% of those screened were normal (Fig. 4; age stratification, Graph 3).

POAG increased with age, from 0.2% in those under 40 years to 10% in those over 80; POAG was more common in men, but OHT was similar in both sexes (6.0% vs. 5.3%). There was no correlation between incidence of POAG and place of work except in the Sorek Nuclear Center (1.9% vs. 0.8%, p=0.11). Other conditions significantly more frequent in POAG than normals were diabetes mellitus (x 2.5), systemic hypertension (x 4), myopia (x 2) and history of intraocular surgery (x 6).

Brief Preoperative Radiotherapy reduces Local Recurrences and Improves Survival in Rectal Cancer

T. Peretz, Z. Weshler,* Y. Goldberg, A.L. Durst, H.R. Freund

Depts. of Surgery and Oncology, Hadassah University Hospitals, and Hebrew University-Hadassah Medical School, Ein Kerem and Mt. Scopus, Jerusalem

Locoregional recurrence of rectal cancer ranges between 20%-50% following apparently radical surgery. Radiation has the potential of reducing this high rate of recurrence and residual disease. A retrospective analysis of 78 patients with locally advanced, biopsy proven, adenocarcinoma of the rectum treated between 1980-1987 was conducted. 28 (36%) were treated by surgery alone (surgery); 29 (37%) by surgery and postoperative radiotherapy (post-op); and 21 (27%) by surgery and preoperative radiotherapy (pre-op). 41 were females and 37 males. The median age was 62 years (range 25-90).

All tumors were resectable. 42 patients (54%) underwent abdomino-perineal resection and 36 (46%) anterior resection patients [8 Dukes B₁ (10%); 37 B₂ (47%); 2 C₁ (3%); 31 C₂ (40%]. Local recurrences were verified by transanal or ultrasound guided needle biopsy.

The 5-year actuarial survival rates by the Kaplan-Meier method for 75 evaluated patients was 55%. Overall 5-year actuarial survival was significantly higher (p=0.001) in pre-op radiotherapy (95%) compared to surgery alone (45%), or surgery with postoperative radiotherapy (32%). The data were significant (p=0.006) for patients with stage B tumors, but not stage C. This trend of improved survival held also at 8-year follow-up (80% pre-op; 32% post-op; 27% surgery). The 5-year actuarial local control was significantly better (p=0.03) for the pre-op irradiated patients (22%), compared with surgery only (56%) and post-op radiotherapy (38%). Local control was better (p=0.02) for Dukes B tumors in the preoperative group, but not Dukes C tumors.

Actuarial 5-year survival of those without distant metastases was 87% for pre-op patients, 62% for surgery alone and 48% for post-op radiotherapy. As all patients were clinically classified as advanced rectal tumors, tumor downstaging by preoperative radiotherapy seems to be paramount for local control. Improved local control translates into a siginificant advantage in overall actuarial survival.

*DECEASED.

Does Incidence of Hepatitis AIncrease During Shmitah (The Sabbatical Year)?

Zvi Ackerman, Ita Goldstein, Elizabeth Ackerman

Depts. of Medicine, Hadassah University Hospital, Mount Scopus; Bikur Holim Hospital; Hebrew University-Hadassah Medical School; and Pediatrics Dept., Kupat Holim, Jerusalem

In Israel the biblical injunction of the sabbatical year (shmitah) prevails, whereby all Jewish-owned land should lie fallow during every seventh year. Consequently, it is customary for members of the orthodox Jewish community to eat only produce grown by non-Jews (Arabs). Many Arab farmers use sewage water for irrigation and since such water could be infected with hepatitis A virus (HAV), there is concern about the possibility of HAV epidemics during the sabbatical year.

We therefore we examined the data of the Israeli Center for Disease Control (ICDC). We found no obvious increase in incidence of viral hepatitis during, nor in the year immediately after, all sabbatical years since 1951. However, the data was not comprehensive as it included only partial information on morbidity from HAV in our Jewish inhabitants. Also, there was no data specific for the orthodox Jewish community, which is especially at risk for HAV from sewage-irrigated vegetables. Irrespective of shmitah, there should be constant effort to prevent HAV infection in Israel.