תוצאת חיפוש

דין עד-אל, דוד אריאלי, רמי נוימן, מנחם רון וכסלר ואריה אלדד

שיחזור שד הפך בדור האחרון לניתוח שיגרתי, המבוצע בחלק גדול מהנשים העוברות כריתת שד. שיפור בתדמית הגוף והתמודדות טובה יותר עם סרטן השד הם מהסיבות שגרמו למנתי השד והמנתחים הפלסטיים להמליץ בחום על הניתוח. ההתקדמות בנושא האיבחון הגנטי של סרטן השד הביאה לעלייה בשכיחות כריות השד למטרות מנע ושיחזורי השד המבוצעים לאחר מכן.

היום ניתן לבחור בין שיחזורים המבוססים על החדרת מרחיבי רקמות לבין ניתוחים המבוססים על השתלת רקמות עצמיות מהבטן, הגב והעכוז. התקדמות זו בשיטות הניתוח מאפשרת להציע למנותחת השד שיחזור המותאם למצבה הרפואי ורצונותיה.

במאמר נסקר נסיוננו בעשור האחרון בשיחזור שד באמצעות תותבת מרחיבת רקמות מסוג

"Becker” ב-229 חולות סרטן השד, תך התייחסות לשיחזורים מריקמה עצמית. במאמר מדווח על אופן האירגון של מירפאה לשיחזור שד, וכן תרשים זרימה להערכה של סוג השיחזור הנדרש ותיכנונו. המגמה בעתיד היא שיחזור המתוכנן באופן פרטני לכל חולה, במסגרת מערכת רב-תחומית תומכת.

Treatment of Traumatic False Aneurysm of the Thoracic Aorta with Stent Graft

R. Avrahami, M. Noyman-Levine, M. Haddad, A. Koren, J. Dahan, G. Sivak, A. Zelikovski,

Department of Vascular Surgery, Rabin Medical Center, Beilinson Campus, Petah Tikva

and Sackler School of Medicine, Tel-Aviv University, Israel

The treatment of traumatic false aneurysm of the thoracic aorta by endovascular stent graft may have advantages over conventional surgery. This is a case study of two women suffering from false aneurysm of the thoracic aorta caused in one by a knife injury and in the other by a car accident. After the patients became hemodynamically stable, a commercially available endothelial stent graft (Talent, Gor) was deployed. Recovery was rapid in the first patient. The second patient required emergency laparotomy for venous bleeding one day after stent placement; she died two weeks later, mainly from organ failure.

Conclusions: Endovascular techniques can be used in selected cases to treat thoracic false aneurysms thereby avoiding the complexity and morbidity of conventional surgery.

עמירה קן-דרור, חנן שניידר, נעמה קונסטנטיני

שירותי בריאות כללית, מחוז חיפה, היח' לטיפול נמרץ לב, בי"ח כרמל, המרכז לרפואת ספורט ולמחקר ע"ש ריבשטיין, מכון וינגייט

פגיעה קהה (blunt) בבית החזה של ספורטאי צעיר עם לב בריא לחלוטין, עלולה לגרום למוות פתאומי כתוצאה מדום לב. למי שנכח באירוע כזה החוויה קשה, מתסכלת ובלתי נשכחת. מצאנו לנכון לסקור תופעה זו, ולהביאה לידיעת ציבור הרופאים; ראשית, כדי לעורר מודעות לקיומה, להכיר אותה ולנסות ללמוד להתמודד עם מניעתה ואופן הטיפול הנכון בעת התרחשותה. שנית, כהזדמנות נוספת לריענון הידע אודות הסיבות הקרדיו-ואסקולריות למוות פתאומי בהקשר עם פעילות גופנית ולסקירת הספרות העדכנית.
 

Plication of Diaphragm for Postoperative, Phrenic Nerve Injury in Infants and Young Children

Yael Refaely, David A. Simansky, Michael Paley, Alon Yellin

Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University

Paralysis of the diaphragm may cause life-threatening respiratory distress in infants and young children because of paradoxical motion of the affected diaphragm and contralateral shift of the mediastinum during expiration. Phrenic nerve injury (PNI) may follow chest operations.

10 children with diaphragmatic paralysis and severe respiratory distress underwent plication of the diaphragm. Ages ranged from 14 days to 5 years. 9 had PNI after operations for congenital heart disease and 1 after resection of an intraspinal cervical lipoma. The right side was affected in 7, the left in 3.

Indication for surgery was inability to wean from mechanical ventilation, which had ranged from 11 to 152 days (median 35). 8 underwent plication via a thoracic approach and 2 via an abdominal approach. There were no complications directly related to the operation.

The interval from plication to weaning from mechanical ventilation ranged from 2 to 140 days (median 4). 1 patient died 2 hours after plication due to severe heart failure and 2 after prolonged hospitalization due to sepsis and multi-organ failure. 6 were extubated 2-8 days (median 4) after plication and 1 only after 40 days.

Early diaphragmatic plication is simple and avoids more serious surgery. While effective in ventilator-dependent infants and young children, it should not be used in those with multi-organ failure. Early plication may prevent the complications of prolonged mechanical ventilation.

Circadian Fluctuations in Efficacy of Streptokinase Thrombolysis

E. Goldhammer, L.Kharash, E.G. Abinader

Cardiology Dept., Bnei-Zion Medical Center and Technion Faculty of Medicine, Haifa

This study was designed to assess possible diurnal fluctuations in the efficacy of thrombolysis with streptokinase. 156 consecutive patients treated with streptokinase during the period 1.1.95-1.7.96 were studied retrospectively. Success or failure of thrombolysis was determined according to the accepted clinical and angiographic criteria starting at midnight, 12 times at 2-hour intervals, then 8 times at 3-hour intervals, and then 6 times at 4-hour intervals. A definite peak for successful thrombolysis was found in the late afternoon and early evening hours. Between 16:00-20:00 PM, in 30.23% successful thrombolysis were observed, compared to 6.98% between 20:00-24:00 PM (p<0.05) and in 10.53% between 00.00-04:00 AM (p<0.05).

Multiple regression analysis showed that the independent factor with the greatest impact on successful reperfusion was the actual time until thrombolysis (p=0.037); then came the interval from pain onset to streptokinase administration (p=0.020), while age and gender had much lesser impacts (p=0.328 and 0.215, respectively), and individual risk factors even less.

These findings may have several clinical implications: dose adjustment for the time of day may be required, with larger doses needed during morning hours, or preference for primary coronary angioplasty to avoid increase in bleeding complications due to higher doses of thrombolytic agents.

Video-Assisted Thoracoscopic Surgery for Diagnosis of Pulmonary Lesions

O. Zamir, Y. Haskel, R. Spira, D. Eimerl, H.R. Freund

Depts. of Surgery and Anesthesiology, Hadassah University Hospital, Mount Scopus, Jerusalem

23 patients (age 11-66 years) underwent video-assisted thoracoscopic biopsy for diffuse disease or peripheral nodular lesions of the lung. 12 had been previously treated for extra- pulmonary malignancy and lung biopsy was done for suspicious metastases. In all cases except 1, lesions were identified and biopsied by thoracoscopy. The postoperative course was easier and shorter as compared to thoracotomy and the mean hospital stay was only 2.5 days. Thoracoscopic lung biopsy is a safe, effective and accurate diagnostic modality for diffuse lung disease and peripheral lesions. It is associated with minimal postoperative pain and discomfort, short hospital stay, early return to normal activity, and gives good cosmetic results.

Multisystem Disease Caused by BCG Imitating Miliary Tuberculosis

I. Tsikonov, D. Yeshurun, J.E. Naschitz

Dept. of Medicine A, Bnai Zion Medical Center and B. Rappaport Faculty of Medicine, The Technion, Haifa

As the prevalence of tuberculosis is on the rise in western countries, we present a 79-year-old man who developed a pulmonary tuberculosis-like syndrome following immunotherapy with BCG for carcinoma of the urinary bladder. The symptoms subsided following 3-drug antitubercular treatment, and the addition of steroids following negative cultures for Mycobacterium tuberculosis. The course of this disease, named BCG-osis, is much more favorable than miliary tuberculosis, even with milder treatment. It is important to keep in mind this phenomenon now that there is increasing treatment of cancers with BCG.

The Fate of Gallstones "Dropped" during Laparoscopy

Menashe Barzilai, Arie Bitterman, Dorit Schlag-Eisenberg, Nathan Peled

Depts. of Radiology and Surgery B, Carmel Medical Center, Haifa

Laparoscopic cholecystectomy is considered the procedure of choice for removing symptomatic, stone-containing gallbladders. It is estimated that in 30-40% of these operations stone(s) spill into the peritoneal cavity. It was assumed that these "dropped stones" are harmless and are dissolved and absorbed spontaneously. We present a 70-year-old woman in whom such a stone, dropped during laparoscopy, led to formation of an intraperitoneal abscess.

Ambulatory Oral Procedures on Low-Dose Aspirin

Ronen Gaspar, Leon Ardekian, Benyamin Brenner, Micha Peled, Dov Laufer

Dept. of Oral and Maxillofacial Surgery, and Thrombosis and Hemostasis Unit, Rambam Medical Center, Haifa

Discontinuation of long-term, low-dose aspirin prior to ambulatory oral surgical procedures was assessed in a blind, controlled prospective study. 50 patients on low-dose aspirin who needed dental extractions, periodontal surgery, or other ambulatory oral surgery were randomly divided into test and control groups. The control patients stopped taking aspirin a week before operation, but in the test group aspirin was continued. Before, during and after surgery bleeding time was tested. Although bleeding time was significantly longer when aspirin was continued, in both groups it was within normal limits. Intraoperative hemorrhage was more frequent in those taking aspirin. Hemostasis control posed no problem and there were no postoperative complications in either group. It is concluded that discontinuing low-dose aspirin prior to elective oral surgery is not justified.

Thoracoscopic Surgery for Spon-Taneous Pneumothorax

H.R. Freund, O. Zamir, Y. Shifman, N. Beglaibter, Y. Haskel

Hadassah University Hospital, Mount Scopus and Hebrew University-Hadassah Medical School, Jerusalem

We report our initial experience with thoracoscopic surgery in the treatment of spontaneous pneumothorax in 14 patients, mean age 30.7 years. 7 were operated following 2 episodes of spontaneous pneumothorax, 6 after their first episode, and 1 after multiple episodes.

All underwent bleb resection, pleurodesis and tube thoracostomy; in 1 we converted to a limited thoracotomy (93% success rate). Only oral analgesia was required for postoperative pain control and patients were discharged 2.6 days after surgery, on average.

The apparent superiority of thoracoscopic over conventional, even limited, thoracotomy seems to justify such therapy even during the first episode.

Investigating Chest Pain: is there a Gender Bias?

Leonardo Reisin, Chaim Yosefy, Sharon Kleir, Emil Hay, Ronit Peled, Shimon Scharf

Cardiology and Emergency Depts. and Epidemiology Unit, Barzilai Medical Center, Ashkelon (Affiliated with Ben-Gurion University, Beer Sheba)

Ischemic heart disease (IHD) in women is characterized by a higher morbidity and mortality in the peri-infarction and coronary bypass peri-operative periods. These epidemiological data strengthen our impression that the health system unintentionally "ignores" the high proportion of females with IHD.

The process of investigating chest pain, diagnosing IHD, and the subsequent treatment and rehabilitation, seem to differ between the genders. Time elapsed from beginning of chest pain to diagnosis of IHD seems to be longer in women than in men. Personal, educational and social factors are contributory.

Although time elapsed between diagnosis and rehabilitation is usually similar in the genders, peri-operative morbidity and mortality are higher in women. It may be that the higher rates in women are caused by delay in diagnosis and treatment, which allows worsening of the disease in women before treatment. This delay can occur during the time needed for evaluation of chest pain, from the door of the physician to diagnosis and treatment.

In our retrospective study we determined the difference in referral of men and women with chest pain to the emergency department (ED) and the attitude of physicians in the ED and medical department to chest pain in men and in women, including final diagnosis on discharge. 615 patients over 18 years referred to the ED for chest pain during 3 randomly chosen, consecutive months were studied. We found that women constituted only 39.5% of the referred patients, but the proportion hospitalized was similar to that in men. Hospitalized women were older (57.7±18.4 versus 49.7±17.8 years in men), and had more risk factors (4 versus 2 in men). Proportions of specific diagnoses on discharge from hospital were equal in the genders.

To bridge the differences and to implement education in prevention, investigation and treatment of IHD in women, we established the "Female Heart" clinic. The objective of this clinic is to reduce differences in the first step, in the process of evaluating chest pain in women, by educating and encouraging them to present early to their physicians, and by changing physicians' attituin the investigation of chest pain in women. We plan to determine in a prospective study if these goals are.

Open Reduction and Internal Sternal Fracture Fixation

Y. Kluger, Y. Paz, N. Gebart, B. Sagie, A. Kremer

Rabin Trauma Center and Dept. of Cardiothoracic Surgery, Tel Aviv-Souraski Medical Center and Sackler Faculty of Medicine, Tel Aviv University

We describe a 63-year-old woman who sustained a sternal fracture after a motor vehicle crash. Due to persistent pain, open reduction and internal fixation of the sternal fracture were performed; recovery was uneventful.

Rupture of Pectoralis Major Muscle: Operative Treatment of an Uncommon Sport Injury

Moshe Weisbort, Gad J. Velan, David Hendel

Orthopedics Dept., Rabin Medical Center (Golda Campus), Petah Tikva

Rupture of the pectoralis major muscle in an athlete is rare, but is said to be common in weight lifters. The muscle usually ruptures at the musculotendinous junction during forceful contraction of the muscle in adduction, forward flexion and internal rotation of the arm. We describe an athlete who suffered such a major tear during a rugby game. It was treated surgically and after adequate rehabilitation, athletic activities were resumed.

Fibrosarcoma after Silicone Breast Augmentation: Associated?

Anabel Aharon-Maor, Yair Levy, Yehuda Schoenfeld

Medical Dept. B, Chaim Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University

We describe a 42-year-old woman in whom bilateral fibrosarcoma of the breast was diagnosed 15 years after bilateral breast augmentation with silicone implants. 3 years prior to admission the implants were replaced and 2 years prior to admission mammography showed a nodule in the left breast which biopsy showed to be fibrosarcoma. The implants were removed from both breasts and she was given chemotherapy but later that year underwent bilateral mastectomy. Despite chemotherapy, as well as adjuvant radiotherapy, the disease progressed, with involvement of the lungs and the skin of the left hemithorax. She was admitted repeatedly for severe anemia caused by bleeding from the malignant skin lesions, and died less than 2 years after diagnosis of the disease.

Not all reports in the literature find a significant connection between silicone implants and subsequent development of breast cancer, but there are reports that do connect them. Breast fibrosarcoma is not significantly more frequent after silicone augmentation, but still there is controversy as to whether there is a connection between silicone implants and breast malignancy. In the patient we present, the prolonged exposure to silicone may have been a predisposing factor for the development of bilateral fibrosarcoma, since other known risk factors for breast cancer were denied.

Skeletonized Internal Mammary Arteries for Coronary Bypass Grafting

Jacob Gurevitch, Yosef Paz, Menachem Matsa, Amir Kramer, Dimitri Pevni, Oren Lev-Ran, H. Locker, Raphael Mohr

Dept. of Thoracic and Cardiovascular Surgery, Sourasky-Tel Aviv Medical Center

The skeletonized internal mammary artery (IMA) is longer, and its immediate spontaneous blood flow is greater than that of the pedicled IMA, thus providing increased versatility for complete, arterial myocardial revascularization without the use of saphenous vein grafts. From April 1996 to May 1997, 583 patients underwent coronary artery bypass grafting here and in 415 (71%) complete arterial revascularization was achieved using bilateral skeletonized IMA. The right gastroepiploic artery was used in 57 (13%); there were 329 males (79%) and 86 women (21%); average age was 64 (30-87) and 175 (36%) were older than 70; 131 (32%) were diabetics. Average number of grafts was 3.2 (range 2-6 grafts). At 30 days, 5 (1.2%) had died and there had been 6 perioperative infarcts (1.4%), 5 CVA's (1.2%), and 6 had sternal wound infections (1.4%). Up to 1-12 months of follow-up was achieved in 409 (99%). Late mortality was 1.4% (of which 3 were noncardiac). 394 (97%) were angina-free at latest follow-up. We conclude that arterial revascularization using bilateral skeletonized IMA is safe, as postoperative morbidity and mortality are low, even in old and diabetic patients.