תוצאת חיפוש

Treatment of Retroperitoneal Sarcoma

Dina Lev-Chelouche, Subhi Abu-Abeid, Mordechai Gutman, Yoram Kluger, Moshe Michovitch, Isaac Meller, Moshe Inbar, Joseph M. Klausner

Depts. of Surgery B, Orthopedic Oncology and Oncology, Tel Aviv - Sourasky Medical Center (Affiliated with Sackler Faculty of Medicine, Tel Aviv University)

Soft tissue sarcomas are exceedingly rare, making up less than 1% of all solid malignancies. In the retroperitoneum, they tend to be large when diagnosed and are a therapeutic challenge to the surgical oncologist. Our experience with 51 patients with retroperitoneal sarcomas operated on during the past 4 years is presented. 37 were primary and 26 presented as recurrent tumors. The group included many different histological sub-types, the majority being high grade tumors.

Complete resection was achieved in 84%, necessitating extensive surgery, but was not possible in 8 patients (16%) who underwent partial resection or biopsy only. There was 1 perioperative fatality (2%). 18 (35%) suffered complications, all of which were reversible. The estimated 5-year survival in the complete resection group is 40%, while none of those who underwent partial resection survived more than 2 years. There was significantly better survival in patients with primary, low grade sarcomas which were smaller than 8 cm, compared to those with high-grade, recurrent sarcomas larger than 8 cm. Local recurrence developed in 8 patients of the complete resection group (18%), 2 months to 3 years after surgery.

These data show that despite the concept of retroperitoneal sarcomas as being aggressive, invasive tumors with a poor prognosis, the prognosis is not unusually bad. With proper surgical technique, resectability may be high, with improved overall survival.

Irradiation Injury of the Salivary Glands

R. M. Nagler

Dept. of Oral and Maxillofacial Surgery and Oral Biochemistry Laboratory, Rambam Medical Center and Technion Faculty of Medicine, Haifa

Ionizing irradiation of the salivary glands often leads to severe histological and functional alterations. Such exposure usually occurs during radiotherapy in patients with head and neck malignancy. The consequent xerostomia, often life-long, may result from even relatively low dosage irradiation, and causes a great deal of suffering. We suggest a radiobiological mechanism for this phenomenon which has been studied extensively since first described in 1911. The suggested injurious role of redox active transition metal ions and highly destructive free radicals is discussed in relation to the ultimate radiosensitive cellular target, DNA.

The Wandering Spleen

A. Ravid, D. Lev, V. Makarin, Y. Klausner, M. Umansky Y. Kluger

Surgery B and C Depts., Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

We describe a 26-year-old woman with thrombocytopenia discovered during gestation. On admission for evaluation of abdominal pain, torsion of an ectopic spleen was found. The spleen was removed and the thrombocytopenia resolved.

The Diagnosis and Treatment of Fournier's Gangrene

M. Cohen, E. Tamir, S. Abu-Abid, Y. Galili, M. Giladi, S. Avital, R. Shafir, Y. Klausner

Surgery and Infectious Disease Depts. and Division of Surgery, Tel Aviv-Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

We treated 2 women and 8 men suffering from Fournier's gangrene during 1990-96. 2 had diabetes, 1 suffered from ulcerative colitis and 1 was an alcoholic. In 8 of them the infection was triggered by a mixture of aerobic and anaerobic bacteria. Treatment consisted of repeated wide debridement and early colostomy. This aggressive approach resulted in relief of the septic signs within 24 hours and permitted early skin grafting of the wounds. 2 patients died due to sepsis that caused multiple organ failure. The 8 who survived were hospitalized for an average of 35 days. On follow-up examination 1-5 years later all patients had undergone closure of the colostomy and were completely rehabilitated.

Fournier's gangrene is not rare in the geriatric population. We believe that early diagnosis and aggressive wide debridement, combined with early colostomy, are the keys to successful treatment.

Epidemiology of Invasive Hemophilus Influenzae B Infections in Bedouins and Jews; Conjugate Hib Vaccines

Limor Gortzak-Uzan*, Drora Fraser, Ron Dagan

Pediatric Infectious Disease Unit and Dept. of Epidemiology, Soroka Medical Center and Ben-Gurion University of the Negev, Beer Sheba

From 1989 to 1996, 139 cases of invasive Hemophilus influenzae B (Hib) infections were identified in children in the Negev, 110 of which occurred before introduction of the conjugate vaccine (1989-92). At that time there were 60.5 cases of Hib per 100,000 in the Negev among children under 5 years of age. During 1995-1996, when Hib conjugate vaccine was part of the regular immunization program, Hib decreased to 6.5 cases per 100,000 in that age group. The effectiveness of PRP-OMP vaccine was 96.5% among Jews and 89% among Bedouins, and the efficacy of the immunization program was 99.99%. This degree of success exceeded all expectations based on the literature. During the whole study period, Hib infections were more frequent among Bedouins than Jews. There was no significant difference in the occurrence of Hib among Jews in the Negev before and after the vaccine was introduced. Hib among Bedouins in the Negev was significantly more frequent than in the Israeli population as a whole before the vaccine was introduced. That gap narrowed after the vaccine was introduced because of the decrease in morbidity among the 2 groups.

* Medical student.

Nerve Preservation during Superficial Parotidectomy

J. Shvero, I. Koren, R. Feinmesser

Depts. of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center (Beilinson Campus), Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University

Sensory loss in the operative area after superficial parotidectomy is one of the complications which disturbs the patient. The greater auricular nerve, which stems from the cervical plexus, supplies sensation to the area. Sacrifice of the nerve during superficial parotidectomy causes sensory loss in the area. We investigated the degree of sensory loss in the operative area after superficial parotidectomy in 10 patients in whom the posterior branch of the greater auricular nerve was preserved and compared the results with those in whom it was not, a year after operation. There was more sensory loss when the greater auricular nerve was sacrificed. We therefore suggest preserving the posterior branch of the greater auricular nerve during superficial parotidectomy if at all possible.

Chylothorax following Penetrating Injury

Y. Kluger, B. Sagie, Y. Chemo, A. Ravid, Y. Paz, J. Klausner

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

We describe a 19-year-old man with 9 stab wounds of the chest. Initial evaluation revealed paraplegia at the D-10 level and bilateral hemothorax. 2 days after admission right-sided chylothorax was diagnosed. Fasting and total parenteral nutrition resulted in complete clearance. Chylothorax can cause major metabolic consequences, but prompt treatment results in full recovery.

Local Treatment of Purulent Chronic Otitis Media with Ciprofloxacin

Ludwig Podoshin, Alexander Brodzki, Milo Fradis, Jacob Ben-David, Josef Larboni, Isaac Srugo

Dept. of Otolaryngology, Head and Neck Surgery, Microbiology Unit and Dept. of Pharmacology, Bnai-Zion Medical Center, and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

We evaluated the efficacy of ciprofloxacin eardrops compared to tobramycin and to a placebo in the treatment of chronic suppurative otitis media. 60 ears were randomly assigned to treatment for 3 weeks with ciprofloxacin, tobramycin or placebo eardrops. The organism most commonly isolated from the ear discharge was Pseudomonas aeruginosa. The clinical responses were 78.9% and 72.2%, respectively, in the ciprofloxacin and tobramycin groups, while it was only 41.2% in the placebo group. Treatment with ciprofloxacin eardrops seemed to be at least as efficient as treatment with tobramycin. Considering the lack of ototoxicity of ciprofloxacin, this treatment may be best for chronic otitis media.

The Parapharyngeal Space: Tumors and Surgical Approaches

E. Raveh, R. Sadov, B. Nageris, R. Feinmesser

Dept. of Otolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva

The potential parapharyngeal space contains the great vessels of the neck, cranial nerves IX-XII, the sympathetic chain and lymph nodes. Surgical access is difficult and the infrequency of tumors in it make surgery of this part of the head and neck a challenge. 8 women and 2 men (mean age 54.7, range 31-70 years) with tumors of the parapharyngeal space operated on during the past 6 years are presented. The most common surgical approach was the cervical submandibular, used in 6 of our patients with relative ease and minimal complications. Tumors of deep lobe parotid origin should be operated through a transparotid approach. Large benign or malignant tumors have a better prognosis when the transcervical transmandibular approach is used, providing wider access.

Balance Disturbances in Children with Middle Ear Effusions

Avishay Golz, Batia Angel-Yeger, Henri Zvi Joachims, Aviram Netzer, S. Parush

Dept. of Otolaryngology and Head and Neck Surgery, Rambam Medical Center and Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Vertigo and dizziness are not common complaints in childhood, but probably present more often than has been thought. These symptoms, caused mainly by otitis media (OM) and middle ear effusion (MEE), are 2 of the most common diseases in children, and until recently had long been neglected in the literature and in practice. We determined objectively the incidence of balance-related symptoms in children with long-lasting MEE, and resolution following insertion of ventilation tubes (VT). 36 children, aged 4-9 years, were studied using electronystagmography (ENG) and the Bruininks-Oseretsky tests for motor proficiency, before and after ventilation of the middle ear. Results were compared to those in 74 healthy children with no history of middle ear disease. Abnormal ENG findings were found in 58%, and 71% had low Bruininks-Oseretsky (BO) test scores. The ENG was abnormal in only 3 of the controls, 1 of whom also had low BO test scores. The symptoms and signs of balance disturbances resolved in 96% following VT insertion. These results indicate that balance-related symptoms often encountered in young children may result from chronic MEE, and that they resolve following evacuation of the effusion and ventilation of the middle ear.

Gradenigo Syndrome and Cavernous Sinus Thrombosis, in Fusobacterial Acute Otitis Media

S. Hananya, Y. Horowitz

Pediatrics Dept., Central Hospital of the Emek, Afula

In this era of antimicrobial medication, intracranial complications following otitis media are rare. We present a 5-year-old boy who suffered from petrositis (Gradenigo syndrome) and cavernous sinus thrombosis as combined complications of acute otitis media caused by fusobacteria. The diagnosis was made using imaging methods suited to the various structures of the skull. Cure was achieved by prolonged conservative treatment with antibiotics, with gallium scan for evaluation of the bone inflammation.

Whipple Operation in Trauma

Y. Kluger, R. Hadad, D. Soffer, D. Aladgem, J.Y. Klausner

Depts. of Surgery A, B, C and Trauma Service, Tel Aviv Medical Center and Sackler Faculty of Medicine, Tel Aviv University

Pancreato-duodenectomy is a formidable operation for the critically injured patient. We describe a patient who sustained a stab wound to the stomach and duodenum. At operation this injury could not be reconstructed. A Whipple operation was performed in which the pancreatic stump was stapled and recovery was uneventful, although there was a low output fistula from the pancreatic stump. Limited indications for the Whipple procedure in trauma patients are suggested.