Biomedical subjects
Publications and source records attributed to A Ayalon.
Mesenteric cysts are uncommon, and their pathological type includes pseudocyst, mesothelial cyst, lymphangioma, and omental cyst. We describe a case of a giant omental cyst treated successfully by a minimally invasive approach.
Laparoscopic splenectomy is effective and technically feasible for treating various hematological diseases such as idiopathic thrombocytopenic purpura (ITP), congenital spherocytosis, hemolytic anemia, and Hodgkin's lymphoma. An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is frequently difficult. The laparoscopic posterolateral approach involves dissection of the posterolateral attachments to the diaphragm, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. We used it in 9 adults and 4 children: 11 patients had ITP, 1 spherocytosis and 1 Hodgkin's lymphoma. This procedure was completed in 13 patients, but in 2 it had to be converted to open surgery. Mean operating time was 3 hours and mean postoperative stay 3 days. Blood transfusion was not required and there were no postoperative complications. Laparoscopic splenectomy is safe in both adults and children, and the posterolateral approach provides excellent visualization and allows control of the branches of the splenic vein and artery in the splenic hilum.
As laparoscopy becomes more prevalent, it is being used for a growing variety of abdominal operations, both electively and as emergency treatment. We describe our preliminary experience in laparoscopic repair of perforated duodenal ulcer. 2 women and 2 men, aged 40-78 were operated over a period of 4 months and in all laparoscopic suture and omentopexy were performed with meticulous abdominal lavage. Despite somewhat longer operative time but a similar period of hospitalization, the easier post-operative course and fewer wound complications justify this technique. The effectiveness of medical treatment of peptic disease, and especially the anti-Helicobacter pylori regimen, supports the view that closure of the perforation is usually enough, and vagotomy is not needed.
Abdominal compartment syndrome refers to a complex of negative effects of intra-abdominal hypertension. Its most common cause is complicated abdominal trauma. The syndrome includes mainly hemodynamic and respiratory manifestations but may involve other systems as well. It may present as a life-threatening emergency in the multi-trauma patient. Awareness of the syndrome may enable the surgeon to take preventive measures or to diagnose it earlier and to treat it effectively. We describe a 21-year old man who developed this syndrome after multiple gunshot wounds, with severe liver injury. After 2 operations the typical manifestations of the syndrome were diagnosed. He was re-operated to release intra-abdominal hypertension and then slowly recovered.
Laparoscopic splenectomy (LS) is effective and technically feasible for treating various hematological diseases, especially idiopathic thrombocytopenic purpura (ITP). An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is often difficult. A total of 13 patients with ITP underwent elective laparoscopic splenectomy. We utilized a laparoscopic posterolateral approach involving dissection of the suspensory ligaments at the lower pole, then dissection and division of the posterolateral attachments, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. This procedure was completed in 11 of our 13 patients and converted to open surgery in the other two patients. Mean operative time was 3 h; mean postoperative stay was 3 days. No blood transfusion was required, and no complications were noted in the postoperative period. The posterolateral approach provides better visualization and control of branches of the splenic vein and artery in the splenic hilum. It also permits visualization and control of surgical hemorrhage through the operating ports.
Benign cecal ulcer is a rare lesion, usually diagnosed during operation for suspected acute appendicitis or peritonitis of unknown origin. In the past, right hemicolectomy was recommended as the treatment of choice because of the difficulty in differentiating malignant lesions from benign cecal ulcers. However, in recent reports a more conservative approach has been suggested, consisting of selective colectomy followed by frozen section biopsy. This approach is aimed at preventing unnecessary excision of the colon and conserving the ileocecal valve. We present a 47-year-old woman operated for right lower quadrant peritonitis, believed to be due to acute appendicitis. On exploration, a biopsy-proven benign cecal ulcer was found and resected.
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The decision whether to perform cholecystectomy during pregnancy, and in what manner, is complex. A 26-year-old pregnant woman was admitted because of persistent biliary colic, which did not respond to conservative treatment. Laparoscopic cholecystectomy was done, with a normal course and without negative effects on the pregnancy. Contraindications to laparoscopic cholecystectomy are becoming fewer as technique improves and experience accumulates. This case report is added to the other few reported, which reinforce the view that pregnancy should no longer be considered a contraindication to laparoscopic cholecystectomy.
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BACKGROUND: A meticulous bilateral neck exploration by an experienced endocrine surgeon offers a high cure rate with low morbidity for patients with primary hyperparathyroidism. The advent of localizing studies raises the possibility of unilateral neck exploration. The cost-effectiveness of preoperative localizing studies and unilateral neck exploration in primary hyperparathyroidism are controversial issues. This study was designed to determine the risks of missing a contralateral pathologic parathyroid gland in patients with preoperative localization that was confirmed at neck exploration. METHODS: Preoperative studies (ultrasonography, nuclear radioactive imaging scan, or both) were performed in 79 patients with primary hyperparathyroidism. In 58 patients a definite localization of an enlarged parathyroid gland was confirmed at operation. All patients underwent a meticulous bilateral neck exploration. RESULTS: Unilateral neck exploration was feasible only in 73.4% of the patients, according to our localizing modalities, and an additional enlarged parathyroid gland on the contralateral side, not detected before operation, was revealed in five patients (8.6%). False-positive rates were 1.7% for ultrasonography and 13% for scan. CONCLUSIONS: These results indicate an unacceptably high surgical failure rate for unilateral neck exploration guided by preoperative localizing studies compared with a bilateral neck exploration by an experienced endocrine surgeon, questioning the cost-effectiveness of preoperative localizing studies.
Spillage of bile and gallstones is not a rare event during laparoscopic cholecystectomy. The natural history of spilled and retained stones is not well defined. We report of such lost stones that were found several months later in a hernia sac.
Meckel's diverticulum is the most prevalent anomaly of the gastrointestinal tract, found in about 2% of the general population. Most are asymptomatic; but most frequent complications are intestinal obstruction, diverticulitis and lower gastrointestinal bleeding. A 33-year-old man was operated on for mechanical small bowel obstruction caused by a large Meckel's diverticulum filled with a phytobezoar. This mechanism of obstruction is rare. When the history of a patient without previous intestinal operations, as in this case, raises the possibility of phytobezoar, the probability of congenital anomaly is high.
A unique case of familial adenomatous polyposis presenting with simultaneous adenocarcinoma of the periampullary region, gallbladder and several gastric lesions, 10 years after a total proctocolectomy, is reported. Multiple gastrointestinal carcinomas associated with familial polyposis have been reported sporadically. However, this is the only known patient who successfully underwent a pancreaticoduodenectomy (Whipple procedure) and a total gastrectomy in addition to a previous total proctocolectomy.
Aging has been associated with specific shifts in various peripheral blood immune competent cell subsets. As part of pre-transplant immune profile evaluation possible parallel age-related changes in mean T-cell surface density of several cluster differentiation and activation linked antigens were into 2 groups: group 1-114 patients 40 years old or younger and group 2-36 patients 55 years old or older. Peripheral blood CD3+, DR+, CD3+DR+, CD4+, CD4+DR+, CD8+, CD8+DR+, CD56+, CD8+CD56+, CD3+IL-2-R+ and CD3+TR+ (interleukin-2 and transferrin receptors bearing CD3+ cells respectively), all mononuclear cells expressing IL-2-R and TR, and CD4+CD45+ cell subsets were analyzed and enumerated by 2-color flow cytometry. Subset relative levels as well as absolute counts were recorded. Cell surface density computation was performed using a computerized mathematical model based on fluorescence intensity vector analysis and cell size score determination based on light scatter pattern from raw data obtained by flow cytometry studies. Younger age was significantly associated with higher absolute cell count of CD3+ (p < 0.001), DR+ (p < 0.05), CD4+ (p < 0.01), CD8+ (p < 0.005), CD3+IL-2-R+ (p < 0.05), CD3+TR+ (p < 0.03) and IL-2-R+ (p < 0.05). Older patients had a slightly higher mean absolute count of CD4+CD45+ subset (p not significant) and significantly higher mean count for CD8+CD56+ cell subset (p < 0.001). When cell subset levels were compared between the 2 groups as the relative fraction of cells expressing a given marker out of all mononuclear cells gated out by flow cytometry, younger age was significantly associated with higher levels of CD3+ (p < 0.005), CD8+ (p < 0.001), CD4+DR+ (p < 0.004), CD3-TR+ (p < 0.05) and CD8+IL-2-R+ (p < 0.05). In contrast, slightly higher subset levels of CD56+ (p not significant), and significantly elevated levels of CD8+CD56+ (p < 0.0019) and CD4+CD45+ (p < 0.004) were observed in the older patients. Cell surface density analysis showed that younger patients had higher mean density per cell of CD3 (p < 0.05), CD8 (p < 0.001), IL-2-R on CD3+ cells (p < 0.05) and TR on CD3+ cells (p < 0.05). Mean cell surface density of CD56 on all CD56+ cells as well as on CD8+ cells was higher in older individuals (p < 0.001 and p < 0.003, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)
During a period of 4 years, 20 patients with obstructing carcinoma of the left colon were treated by subtotal colectomy with primary ileocolonic anastomosis. Thirteen patients (65%) were 65 years of age or older. All patients presented to the emergency room with large bowel obstruction. Twelve patients (age > 65) suffered other systemic diseases (chronic obstructive pulmonary disease, ischemic heart disease, morbid obesity), placing them in a high risk category. The mortality rate was 5% (1/20), 7.6% if only high risk patients are considered. The one-stage procedure in the treatment of obstructing carcinoma of the left colon offers the patient a number of advantages over stage intervention elimination of colostomy, namely removal of occult lesions in the resected colon, shorter hospitalization and low morbidity and mortality. We found this procedure to be a valid option also in the elderly (> 65) high risk patient. Metastatic disease in our view is not a contraindication, since the elimination of colostomy will improve the quality of life of these patients.
A direct surgical approach to the MHV during left-sided hepatectomy is anatomically feasible. The procedure should be applied with appropriate safety measures. Prior verification of the precise anatomic relationship of the hepatic veins is necessary and the MHV should be isolated and secured by the described stepwise technique.
Pyridostigmine has a protective effect against organophosphate poisoning when given in a dosage of 30 mg three times daily causing 20-40% cholinesterase inhibition. To test its safety in the human neuromuscular system, a double-blind study on 35 subjects divided into two matched groups was performed. One group was treated with pyridostigmine in a dose of 30 mg three times daily and the other group was treated similarly with placebo, both for a 10-day period. The resultant average cholinesterase inhibition in the treatment group was 23%. Muscle strength and endurance were tested before, during (on the 8th day), and after treatment. Electrodiagnostic studies, including nerve conduction, electromyography, and response to repetitive stimulation, were carried out on four subjects of the treatment group and on two subjects of the placebo group, both before and during treatment (eighth day). Isometric handgrip strength, isokinetic elbow flexor, and extensor strength did not differ between groups as a result of the treatment. Knee flexor and extensor isokinetic strength showed a small (but statistically significant) trend to improve more during placebo treatment, whereas knee extensor endurance decreased slightly in the placebo group. Both these effects are probably due to large fluctuations in performance of the placebo group, whereas the treatment group performance was quite constant. They probably do not represent any adverse effect of pyridostigmine. No electrophysiological changes were found in any of the subjects during treatment. We conclude that pyridostigmine does not cause any significant neuromuscular effect in healthy subjects when taken in a dosage of 90 mg daily for 8 days, causing 20-30% inhibition of cholinesterase.
Calcium metabolism and hormonal control after parathyroid adenomectomy are poorly understood. During the first postoperative hours, biologically active intact parathyroid hormone (PTH) (hPTH 1-84) levels are subnormal and, in spite of down-regulation of PTH peripheral receptors (caused by hypercalcemia before surgery), total and ionized calcium concentrations are maintained in the normal range. Serum samples from 20 patients with primary hyperparathyroidism were collected in the immediate preoperative period and 4 and 48 hours after excision of one parathyroid adenoma. Total and ionized calcium, intact (iPTH), midregion (mrPTH) specific PTH (hPTH 53-68), and N-terminal PTH (N-PTH) serum concentrations were determined. Levels of N-PTH were obtained with a radioimmunoassay by a modified reverse immunoextraction procedure that measures N-PTH fragments after exclusion of the interfering iPTH. No significant correlation was found between ionized and total calcium, mrPTH, and iPTH. However, total and ionized calcium levels correlated well with N-PTH (r = 0.9999, p = 0.0054, and r = 0.9993, and p = 0.0226, respectively). The data suggest that the relatively moderate decrease in calcium levels, in spite of marked decrease in circulating iPTH during the first postoperative hours, may be attributable to the minimal decrease of the bioactive N-PTH epitope concentrations. We would hypothesize that hPTH (1-34) fragments may play a significant role in regulating serum calcium levels in the early postoperative period.