תוצאת חיפוש

רונן רובינשטיין, גבריאל ובר, חיים ביטרמן

המח' לרפואה פנימית א' והיח' למחלות זיהומיות, מרכז רפואי כרמל, הפקולטה לרפואה רפפורט, טכניון, חיפה

לנוכח היישום הגובר והולך של טיפולים מדכאי מערכת-החיסון, תיתכן עלייה בשיעור החולים הלוקים בדלקת-ריאות עקב זיהום ב-Pneumocystis Carinii, ההנחיות למנע, איבחון וטיפול במחלה זו מבוססות בעיקר על מידע רב שהצטבר בעקבות טיפול בחולים עם תיסמונת הכשל החיסוני הנרכש (AIDS) (תכח"נ). עם זאת, המודעות והמידע אודות מאפייני המחלה והטיפול בה בחולים ללא תכח"נ פחותים בהרבה. ככלל, המחלה מופיעה בחולים עם מחלות בהן קיים דיכוי חיסוני (לדוגמה, מחלות ממאירות של מערכת הדם) ובחולים המקבלים טיפול לדיכוי חיסוני, בעיקר חולים המטופלים בסטרואידים, קצב התקדמות המחלה מהיר יותר מאשר בחולי תכח"נ, ושכיחה הימצאותם של זיהומים צולבים נוספים – בעיקר מנגיף הציטומגלו ומשמרי הקנדידה. משך הטיפול המומלץ מעט קצר יותר מאשר בחולי תכח"נ, והסבילות לטיפול טובה יותר. למרות קיום טיפול יעיל, שיעור התמותה ממחלה זו עדיין גבוה, והוא מחייב מודעות גבוהה של הצוות הרפואי ועף התחלת טיפול מהירה, עוד בטרם נקבעה אבחנה סופית.

יוני וינר (1), אורנה דלי גוטפריד (1,2), אנטוני לודר (1,2), פנחס השקס (1,3)

המח' לרפואת ילדים, בית-החולים זיו, צפת (1), שירות לריטולוגיית ילדים, בית-החולים פוריה(2), והפקולטה לרפואה, הטכניון, חיפה

בהמשך למאמרנו, שבו נדונה סוגיית הטיפול בפאראצטמול בילדים, ובו דנו ביתרונות ובחסרונות שטומן בחובו טיפול זה, ברצוננו להצביע בסקירתנו זו על חלופה אפשרית שבימים אלה נכנסה כטיפול בילדים. מדובר באיבופרופן שהיא בבחינת תרופה ותיקה, שבימים אלה נמכרת בישראל בצורת תרחיף המיועד לטיפול בילדים. זמין לכל, ללא צורך במירשם רופא. משנת 1989 הצטבר ניסיון קליני רב בטיפול באיבופרופן. בשנים האחרונות החלו להתפרסם דיווחים על טיפול מוצלח באיבופרופן בהורדת חום בילדים, והתוצאות בולטות, בעיקר נוכח מיעוט השפעות-לוואי.

Laparoscopic Cholecystectomy - 1,000 Procedures in a Surgical Department

Uri Freund, Ami Mayo, Ivan Schwartz, David Neufeld, Haim Paran

Dept. of Surgery A, Meir Hospital, Kfar Saba; and Sackler School of Medicine, Tel Aviv University

The first 1,000 laparoscopic cholecystectomies performed in our department were reviewed. There was no operative mortality; conversion to open cholecystectomy was necessary in 2%. In the last 600 cases the rate of conversion had decreased to 0.5%. There was common bile duct injury in 0.3%, with the injuries identified during primary surgery. This clinical experience is consistent with previous studies, which proved that laparoscopic cholecystectomy is safe and should replace open operation as the procedure of choice. 

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.

Multilocular Cystic Mass of the Kidney: A Diagnostic Challenge

Judy Kleinmann, Simon Negelev

Urology Dept., Assaf Harofeh Medical Center, Zerifin

Multilocular cystic masses of the kidney present a diagnostic challenge because they may be malignant. Renal cell carcinoma with multilocular cysts has been reported. We present 4 cases in which the preoperative differential diagnosis was between a benign and a malignant multilocular cystic kidney mass.

Our results, combined with those of 33 previously reported cases, reveal that only 32% of cases were diagnosed correctly preoperatively. In 21% of these patients the preoperative clinical evaluation did not correctly diagnose malignancy: 24% of them yielded false negative and 21% false positive results. Angiography was more accurate than CT, US or aspiration of cysts. Frozen section was inaccurate in 55% of cases.

There is no reliable diagnostic test to distinguish between a malignant and a benign multilocular cystic mass. Invasive angiography is more accurate than other modalities. A therapeutic decision has to be made between nephron-sparing and radical surgery in each case. When nephron-sparing surgery is considered, the possible need to perform radical nephrectomy in second-look surgery must be taken into account.

Monocytic Ehrlichiosis - An Emerging Pathogen

Irena Zikonov, Israel Potasman

Dept. of Internal Medicine A and Infectious Disease Unit, B'nai Zion Medical Center and Technion Faculty of Medicine, Haifa

Ehrlichiosis is an emerging zoonotic disease transmitted to man by ticks. Its clinical features include fever, headache, myalgia, nausea and rash. The diagnosis requires a high index of suspicion; the disease has a specific serology, and has never been reported in Israel.

We describe a 52-year-old man hospitalized with fever, a diffuse rash, arthralgia and epididymitis. Skin biopsy disclosed necrotizing small vessel disease consistent with periarteritis nodosa. Acute phase serum titer for E. chaffeensis was 1:256. Fever promptly subsided following ciprofloxacin.

Radiologic Appearance of "Falling Gallstones" during Laparoscopic Cholecystectomy

E. Alkalay, D. Yaffe, Z. Spindel

Eyn Vered Clinic and Depts. of Radiology and Surgery, Sapir Medical Center, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University

Laparoscopic cholecystectomy is the "gold standard" in treating cholelithiasis. Stones are frequently lost in the peritoneal cavity during the procedure, but "missing stones" have been regarded as insignificant. However, there is accumulating evidence that untreated "lost" stones may cause complications even years after operation.

We present a 65-year-old woman who presented with vague complaints, anemia and an elevated ESR. CT scan showed an infiltrating process in extra-abdominal muscles compatible with sarcoma. At operation, 2.5 years after previous laparoscopic cholecystectomy, an abscess was found which contained biliary stones. Because of their small size they were not visible on CT scan. We discuss the possible ways of handling "falling stones."

Intra-Osseous Ganglion of Scaphoid and Lunate Bones

M. Kligman, M. Roffman

Dept. of Surgery, Carmel Medical Center, Haifa

We present a patient with intra-osseous ganglion of the left scaphoid and lunate bone. These were excised and a bone graft inserted. 1 year after operation the patient was free of pain, without limitation of wrist motion. Intra-osseous ganglion of the carpal bone is not common and lunate and scaphoid intra-osseous ganglion has rarely been reported. Awareness of this condition may lead to earlier diagnosis and treatment, with satisfactory outcome.

Epidermoid Cyst of the Spleen

Dan Bar-Zohar, Yaniv Sherer, Hana Manor, Amir Peer, Simon Strauss, Ariel Halevy

Dept. of Surgery B and Institute of Radiology, Assaf Harofeh Medical Center, Zerifin, and Sackler Faculty of Medicine, Tel Aviv University

Splenic cysts are rarely found or diagnosed. Excluding cases of trauma, the events preceding their development have not been fully understood. We describe a 22-year-old woman in her 34th week of pregnancy in whom ultrasound revealed a cystic lesion 8610 cm. in diameter in the left upper abdomen. Further imaging tests followed by laparotomy confirmed the splenic origin of the cyst. Splenectomy was performed and the lesion was histopathologically defined as an epidermoid cyst.

Gastric Duplication Cyst in an Adult

D. Estlein, Y. Wolloch

Dept. of Surgery B, Rabin Medical Center (Golda Campus), Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University

Gastric duplication cysts are rare in adults and usually asymptomatic. In most cases they are discovered incidentally by abdominal ultrasound, CT, or upper gastrointestinal x-rays. Most of the duplications (82%) are cystic and do not communicate with the stomach. Approximately half of the cases are associated with other congenital anomalies. We report a 59-year-old woman operated on for a pancreatic mass that proved to be a gastric duplication cyst. The cyst was resected and the postoperative course was uneventful.