Thrombosis of superior vena cava during total parenteral nutrition, managed successfully with low dose streptokinase.

Superior vena cava syndrome due to catheter related thrombosis, developed in a patient receiving total parenteral nutrition. Local infusion of low dose streptokinase immediately proximal to the thrombus, was strikingly successful and may be the treatment of choice for this condition.

Partial distal pancreatectomy with a hand-held CO2 laser. An experimental study.

Partial distal pancreatectomy was performed in dogs with CO2 laser. Results were compared with those obtained with use of diathermy and scalpel. Postoperative hyperamylasemia appeared in all the animals. The highest peaks in the laser and scalpel groups were found on the fifth postoperative day, after which they gradually returned to normal; the highest levels appeared in the diathermy group on the 21st day, and returned to normal only after 56 days. Pancreatography showed a sealed duct in the laser and diathermy groups although no duct ligation was performed. Histological study of the laser group disclosed initial thermal injury at the cut section with no damage to the nearby parenchyma, followed later by a smooth, thin scar. In the diathermy and scalpel groups, the injured zone became enlarged later by active parenchymal and interlobular inflammation in the underlying tissue.

Experimental acute pancreatitis. Inducement by taurocholate sodium-trypsin injection into a temporarily closed duodenal loop in the rat.

Experimental pancreatitis induced by permanently closed duodenal loop results in death of the experimental animal. Acute pancreatitis can be induced in the rat by injection of taurocholate sodium-trypsin solution intraluminally into a temporarily occluded duodenal loop. Mortality in this model was 45% within one week after injection. Mean serum amylase level was greatly increased above that in control rats that underwent temporary duodenal ligation without intraduodenal injection of fluid. The presence of pancreatitis was confirmed by histological examination. The advantage of the temporarily occluded pancreatitis model is that the animal can survive if the stimulus is not excessively severe.

Surgery in Israel.

The evolution and development of surgery in Israel reflects the influence of its dramatic historical events. The immigration of surgeons, particularly since the fourth decade of the 20th century, highly contributed to the framework of modern surgery. Medical education occurs at 4 medical schools, in Jerusalem, Tel Aviv, Haifa, and Beer Sheva, and postgraduate surgical training takes place in all public hospitals, most of which are university hospitals or have university-affiliated departments, and is controlled by the Scientific Council of the Israel Medical Association (Tel Aviv). Health care is provided by 4 health insurance funds and has been recently influenced by the National Health Insurance Bill and the Bill of Patient's Rights. Surgical standards are high and similar to the very best of Western countries. The geographical location of Israel in the Middle East, surrounded by hostile Arab countries, has dramatically influenced the development of Israeli surgery. The practice of surgery ranges from full-time service in state and insurance-funded mostly academic hospitals, to private part-time clinics for wealthy and insured patients. Surgical training occurs only in departments accredited by the Scientific Council, which are mostly affiliated with the 4 medical schools. A surgical residency in Israel usually requires 6 years, and its guidelines and regulations are elaborated and recommended by the Israel Surgical Society and controlled by the Scientific Council. Most Israeli surgeons were trained in Israeli hospitals, but a substantial number of surgeons immigrated to the country, especially from eastern Europe.

Richter's hernia--a surgical pitfall.

BACKGROUND: Although Richter's hernia was first described in 1598, little attention has been given to this topic in recent literature. The diagnosis of Richter's hernia is difficult because of the innocuous development of signs and symptoms and it is associated with a high mortality rate. Awareness of this relatively rare surgical entity is important. STUDY DESIGN: Of 350 patients with incarcerated hernias who underwent operation between 1977 and 1994 at the Department of Surgery "A," Assaf Harofeh Medical Center, 14 had strangulated Richter's hernia. A retrospective study was carried out in order to characterize the clinical manifestations of Richter's hernia and to assess preoperative delay, hospital stay, and complication and mortality rates. A comparison study was made with matched patients with strangulated hernias of non-Richter's type. Differences in morbidity and mortality rates, preoperative delay, and hospital stay of patients with Richter's hernias and the comparison group were evaluated. RESULTS: Of 14 patients with Richter's hernia, seven underwent intestinal resection. The hernia most commonly occurred at the femoral and inguinal sites. Compared with patients with other hernias, patients with Richter's hernias had greater preoperative delay, rate of bowel resection, length of hospital stay, and postoperative morbidity and mortality rates. CONCLUSIONS: Early operative intervention is the mainstay of successful management of Richter's hernia and awareness of this disease and its misleading clinical presentation is of utmost importance.

Bilateral localized Castleman disease of the retroperitoneum.

A case report of a 23-year-old patient with abdominal pain was found to have a bilateral, retroperitoneal localized form of Castleman disease. To the best of our knowledge, it is the first report of a bilateral form described in the literature. Surgical excision resulted in the disappearance of symptoms and both masses were found to be of the hyaline type. Follow-up computerized tomography revealed no pathological sequelae.

99Tcm-MIBI scintimammography for the detection of breast malignancies: the contribution of the count ratio to specificity.

We evaluated the efficacy of 99Tcm-sestamibi (MIBI) scintimammography for the detection of breast cancer in 332 patients. Two hundred and seven scans were confirmed by histological or cytological results; the other patients were examined because they belonged to high-risk groups or had dense fibroglandular breasts. Of 207 patients with histological confirmation, 112 positive studies were obtained: 86 true-positive and 26 false-positive. Scintimammography was negative in 95 patients: 88 true-negative and seven false-negative. Six of seven false-negative results were obtained in patients with impalpable tumours. The sensitivity, specificity, positive and negative predictive values were 92.5%, 77.2%, 76.8% and 92.6% respectively. The overall accuracy was 84.1%. To identify false-positive results, the count ratio of the target lesion to the contralateral normal area on 38 true-positive scans and in 26 false-positive examinations was calculated from the region of interest drawn on the 99Tcm-MIBI scan (L/N ratio). A significantly higher ratio was found for the true-positive scans (1.583 +/- 0.501 vs 1.246 +/- 0.213; P = 0.0002). In conclusion, 99Tcm-MIBI scintimammography is a sensitive and accurate method for the detection of breast malignancies.

99Tc(m)-tetrofosmin scintimammography for detecting breast cancer: a comparative study with 99Tc(m)-MIBI.

Scintimammography using 99Tc(m)-MIBI (99Tc(m)-sestamibi) has demonstrated promising results in the detection of breast cancer. Recently scintimammography using 99Tc(m)-tetrofosmin has been suggested as a better diagnostic tool and a more convenient agent to use in this condition. In this study we compared both agents in 35 consecutive women with abnormal mammographic or physical findings. Thirty-four of them underwent MIBI scan, followed by tetrofosmin scan 2 days later (performed on all 35 women). Within 2 weeks, a pathological diagnosis was obtained either by needle or open biopsy. In both scans the uptake ratio between the lesion and the background uptake was calculated. Twenty patients who underwent tetrofosmin scan and 19 patients with MIBI scan had malignant breast tumours, while 15 women had benign lesions. The sensitivity, specificity, positive and negative predictive values and total accuracy of the MIBI scan were 89.4%, 80%, 85%, 85.7% and 85.3%, respectively; almost identical values were obtained with tetrofosmin (90%, 80%, 85.6%, 85.7% and 85.7%, respectively). The uptake ratios in the MIBI and tetrofosmin scans were 1.68 +/- 0.52 and 1.7 +/- 0.47, respectively. No differences were found between the two scintimammographies in all the parameters examined. In conclusion, MIBI and tetrofosmin breast scans are accurate and equally efficient for the detection of breast malignancies.

Hemisplenectomy using a hand-held CO2 laser. An experimental study.

Hemisplenectomy was performed in mongrel dogs using a hand held CO2 laser. Cutting and hemostasis were performed by a laser beam with a high concentration power--about 6kW/mm2--at the focal spot, and residual bleeding was controlled by using a defocused beam. The cutting action was improved by temporary closing of the arterial vessels and by injecting adrenaline into the splenic artery to produce a relatively dry surface. The surgical procedure was free of mortality or morbidity. Histological studies revealed a brand of fibrous tissue at the cut surface, without apparent abnormalities in the splenic parenchyma beneath the section. Activity of the residual half spleen was shown by postoperative technetium scan and by the fact that Howell-Jolly bodies appeared in peripheral blood only after resection of the remaining half spleen.

Intra-operative ultrasonography as a routine screening procedure in biliary surgery.

Intra-operative cholangiography and ultrasonography were compared in screening for unsuspected common bile duct stones. In 57 consecutive patients both procedures were performed, and in 60 only ultrasonography was used. Although the study was conducted during the initial self-teaching period (regarding ultrasonography) the results show an advantage of this relatively new diagnostic technique. The false positive rate was lower and consequently the predictive value of a positive test was higher for intraoperative ultrasonography. The main benefit would thus be a lower rate of negative common bile duct explorations. Our early results suggest that the general surgeon would need only a short adaptation period to this imaging modality, which would seem to be a valuable alternative to intra-operative cholangiography.

Replacement of ruptured aneurysm of arteriovenous fistula by segmental frozen venous allograft: a case report.

A ruptured aneurysm of an arteriovenous fistula created for chronic hemodialysis was replaced by a segment of frozen saphenous vein allograft. Fifteen months following the procedure the graft is patent. Frozen vein allografts should be considered as an appropriate option for the reconstruction of disrupted A-V fistulae.

Familial retrocaecal appendicitis.

Four members of the same family operated on for acute retrocaecal appendicitis are reported. It is suggested that they provide further support for the hypothesis that an hereditary factor might be involved in the pathogenesis of acute appendicitis.

Bolus high dose interleukin-2 for the treatment of malignant melanoma.

BACKGROUND: High dose interleukin-2 therapy, administered in bolus, is considered to be a reasonable treatment option in a selected group of patients with metastatic malignant melanoma. OBJECTIVES: To present our experience using this mode of therapy in 21 patients with metastatic melanoma. MATERIALS AND METHODS: The 21 patients in our study group comprised 13 men and 8 women with a mean age of 46 years (range 29-63). Their metastatic disease was present in all extracranial sites, dermal and sub-dermal metastases being the most common (15 patients had at least one site, in addition to other locations of metastases). Patients with intracranial disease were excluded due to the poor effectivity of IL-2 at this site. Treatment comprised a course of 2 weeks of therapy with a 1 week rest interval between. Radiological and physical evaluation was performed 6-8 weeks after the first course. If a response was achieved a second course of therapy was given. Patients received up to 14 planned doses of IL-2 in each week, 720,000 IU/kg of IL-2 per dose i.v. in 15 minutes. All treatments were given in the surgical ward, and only one patient was hospitalized in the intensive care unit. RESULTS: Of the 21 patients, one had a complete response that has lasted for 17 months and 5 patients had a partial response (range 3 months to 3 years). One patient died during treatment, and one patient who refused further treatment because of no response died a few days after completion of treatment. Prior to therapy three of the responders had received autologous vaccines with good immunological response (P = 0.115). Toxic side effects were significant, but they were treated successfully with no residual damage. CONCLUSIONS: High dose IL-2 can be administered safely in a surgical department. The response rates achieved in this series justify the use of high dose IL-2 in a selected group of patients. To improve response rates, a combination of autologous vaccines prior to high dose IL-2 may be recommended.

Chlamydia trachomatis and inflammatory bowel disease--a coincidence?

Serological tests of 35 patients suffering from inflammatory bowel disease were compared to those of 35 healthy controls. The tests were performed using the indirect immunoperoxidase assay. Ninety-three per cent of 15 patients with Crohn's disease had IgG antibodies against Chlamydia, compared to 26% in the control group. In the 20 patients with ulcerative colitis, 45% had IgG antibodies against Chlamydia, compared to 10% in the control group. High serum titres of IgG antibodies were found in most of the patients with inflammatory bowel disease, mainly with Crohn's disease, while weak reactions appeared in most of the controls in which antibodies were detected. These results suggest a high incidence of Chlamydia infection in the studied patients with inflammatory bowel disease, especially in those with Crohn's disease. The possible association between Chlamydia trachomatis and inflammatory bowel disease is discussed.

[Liver damage after exposure to halothane].

A 70-year-old woman developed fever accompanied by impairment of liver function and eosinophilia after 2 courses of halothane anaesthesia given within a few days. Serologic tests excluded viral hepatitis. Liver function and blood count returned to normal within 2 weeks. When a second operation is necessary shortly after a previous anesthesia with halothane, a different, non-hepatotoxic agent should be used.

[Sutureless intestinal anastomosis with a biofragmentable anastomotic ring].

There have been efforts to develop an ideal method of intestinal anastomosis throughout medical history. In ancient China, Egypt and India living ants were used to approximate the transected edges of bowel. Many other devices and techniques have since been introduced, using organic or synthetic, nonabsorable or absorbable materials. Lately mechanical stapling devices have become exceedingly popular. The recently introduced biofragmentable anastomotic ring (BAR) is composed of an absorbable polyglycolic acid in 12.5% barium sulfate suspension to permit x-ray visualization. Prospective randomized studies have shown it to be both effective and safe as compared to conventional handsutured or stapled anastomosis. Its main advantages are simplicity and ease of handing, short operating time and the absence of foreign bodies at the anastomotic site that might interfere with imaging methods, such as CT or MRI. We present our preliminary, satisfactory experience with BAR in 14 patients with a mean age of 67 years. 8 underwent right colectomy, 2 left colectomy, 1 sigmoidectomy, 2 resection of upper rectum, 1 subtotal colectomy, 1 excision of a giant lymphoma of the cecum, and 1 had had recurrent bouts of volvulus of the sigmoid.

[Primary breast tumor and malignant phyllodes tumor of the breast-- two rare cases demonstrated by technetium 99m scintimammography].

Breast cancer can be detected by scintimammography using Tc-99m sestamibi (MIBI). The method is highly accurate, sensitive and specific. Histologically, most of the tumors have been adenocarcinomas. We present 2 women with rare breast tumors, primary squamous cell carcinoma and malignant phyllodes tumor. In both, mammography and cytological biopsy were not diagnostic, but MIBI scintimammography demonstrated focal uptake in the diseased breast.

[Local thrombolytic therapy for axillary vein thrombosis].

Deep vein thrombosis of the upper limb is much rarer than that of the lower limb. Despite conventional treatment with systemic heparin, there are residual symptoms in many patients. An alternative method of local thrombolytic therapy was used with success in a 30-year-old-women with thrombosis in his arm. 1 year later s/he is well and symptom-free.