Publications (19)78.63 Total impact
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Article: Resection margins in ultrasound-guided breast-conserving surgery.
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ABSTRACT: Few published studies have shown the benefits of intraoperative ultrasound in avoiding inadequate margins in breast-conserving surgery. The aim of this study is to quantify intraoperative ultrasound margin size and assess its relationship to tumor size, multifocality, palpability, histology, and presence of intraductal component. Patients with breast cancer undergoing breast-conserving surgery in whom the operating surgeon visualized the tumor by ultrasound were included. Ultrasound margins measured intraoperatively were prospectively recorded and compared with pathology margins. Forty-five patients with 48 tumors were included. Twenty five patients (56%) had palpable tumors. Pathologic mean tumor size was 1.9 cm [95% confidence interval (CI) 1.6-2.2 cm, range 0.5-4.8 cm]. There was good correlation between closest margins recorded by ultrasound and pathology margins (r = 0.4674, P < 0.0008). Fourteen patients (31%) had margins re-excised intraoperatively, 12 of them in the direction of the closest pathological margin. Three patients (7%), all of whom had intraoperative re-excision, had a second operation for involved margins without residual cancer on pathological examination of the reoperative specimens. Ultrasound margins ≥0.5 cm achieved adequate pathology margins of ≥0.2 cm in 95% of margins. Overestimation of pathology margins by ultrasound measurement was significantly affected by multifocality (P = 0.0473). Tumor size, palpability, invasive lobular histology, and presence of ductal carcinoma in situ (DCIS) did not cause significant overestimation of pathology margins by ultrasound. Intraoperative ultrasound may help maintain a low level of reoperation after breast-conserving surgery. Ultrasound margins <0.5 cm should be re-excised intraoperatively. Reliability of ultrasound in predicting the closest pathology margins was diminished in patients with multifocal tumors.Annals of Surgical Oncology 02/2011; 18(2):447-52. · 4.17 Impact Factor -
Article: Selection of patients with severe pelvic fracture for early angiography remains controversial.
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ABSTRACT: Patients with severe pelvic fractures represent about 3% of all skeletal fractures. Hemodynamic compromise in unstable pelvic fractures is associated with arterial hemorrhage in less than 20% of patients. Angiography is an important tool in the management of severe pelvic injury, but indications and timing for its performance remain controversial. Patients with major pelvic fractures [Pelvic Abbreviated Injury Score (AIS) >or= 3] admitted to two high volume Trauma Centers from January 2000 to June 2005 were identified and divided into two groups: Group I patients did not undergo angiography, Group II patients underwent angiography with/without embolization. Demographics, hemodynamic status on admission, concomitant injuries, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), pelvic AIS, blood requirement before and after angiography, arterial blood gases and mortality were evaluated. Patients with an additional reason for hemodynamic instability were excluded. Charts of 106 patients were retrospectively reviewed. Twenty nine patients (27.4%) underwent angiography. Bleeding vessel embolization was performed in 20 (18.9%) patients. Patients who underwent angiography had a significantly higher pelvic AIS and a lower Base Excess level on admission. A blood transfusion rate of greater than 0.5 unit/hour was found to be a reliable indicator for early angiography. A high pelvic AIS, amount of blood transfusions and decreased BE level should be considered as an indicators for early angiography in patients with severe pelvic injury.Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 11/2009; 17:62. · 1.85 Impact Factor -
Article: Right-sided "trapdoor" incision provides necessary exposure of complex cervicothoracic vascular injury: a case report.
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ABSTRACT: Combined cervicothoracical vascular traumas are very uncommon, mostly resulting from penetrating injuries. These injuries are accompanied with very high morbidity and mortality rates. In this manuscript we present a case of hemodinamycally unstable trauma patient whose major injury was penetrating trauma of both cervical and mediastinal major vessels. The standard surgical approach of median sternotomy and neck incision was insufficient, and the patient's instability forced the authors to improvise previously not described right-sided trap-door thoracomy. Incorporation of such incision in the surgical arsenal may be very effective in selective cases.Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 09/2009; 17:46. · 1.85 Impact Factor -
Article: Abdominal stab wounds in Israel, 1997-2004: significant increase in overall incidence and prevalence of severe injury.
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ABSTRACT: Non-operative management following abdominal stab wounds is possible in selected patients who are both hemodynamically stable and do not have signs of peritonitis. However, the rate of failure of non-operative management is higher in Israel than in western countries. To assess the patterns of injury following abdominal stabbing. Data from the Israeli Trauma Registry were used to identify all patients with abdominal stab injury admitted to eight different trauma centers between 1997 and 2004. The number of patients admitted per year more than doubled between 1997 and 2004, from 257 to 599. The percentage of patients with severe injury (Index Severity Score > or = 16) increased from 9.4% to 19.0%. The incidence of multiple stab injuries almost doubled, from 37% to 62%. Review of the data in the Israeli Trauma Registry indicates an increase in both absolute rate and relative incidence of serious stab injuries. This indicates that patterns of injury following stab wounds are not necessarily similar, not even within the same geographical area over time.The Israel Medical Association journal: IMAJ 02/2008; 10(2):135-7. · 1.02 Impact Factor -
Article: Papillary lesions of the breast discovered on percutaneous large core and vacuum-assisted biopsies: reliability of clinical and pathological parameters in identifying benign lesions.
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ABSTRACT: A review of the literature reveals conflicting evidence on whether core biopsy, complemented with concordant imaging, is sufficient in differentiating benign from malignant papillary lesions. Our objective was to evaluate whether in our patient population, commonly used clinical and pathological parameters could predict benignity, thus eliminating the need to proceed with excision. A retrospective review of clinical variables and pathologic slides of 39 patients in whom both core biopsy and excisional biopsy were available for evaluation. Excision revealed malignancy in 44%. Risk factors for malignancy, palpability, size, or Breast Imaging Reporting and Data System (American College of Radiology, Reston, VA) did not help differentiate benign from malignant disease. Younger age and core biopsies revealing minimal or no atypia were predictive of benignity. However, 4 (25%) of 20 patients whose core biopsies were classified as probably benign were found to have malignancy on excision. Caution should be used in recommending nonoperative management after a core biopsy revealing a papillary lesion.American journal of surgery 09/2007; 194(2):183-8. · 2.36 Impact Factor -
Article: Effect of teleradiology upon pattern of transfer of head injured patients from a rural general hospital to a neurosurgical referral centre.
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ABSTRACT: To assess the effect of teleradiology upon the need for transfer of head injured victims requiring hospitalisation but referred initially to a rural level 2 trauma centre without neurosurgical capacity. Head injured patients requiring hospitalisation, admitted to a rural level 2 trauma centre between August 2003 and August 2005, were identified. A digitalised copy of the computed tomographic (CT) scan was transferred to the neurosurgical referral centre via teleradiology and was available for review by the neurosurgeon on-call, who then, together with the trauma surgeon in the rural level 2 trauma centre, decided whether to transfer the patient to the neurosurgical referral centre. Of 209 trauma victims with neurosurgical pathology in need of hospitalisation, 126 (60.2%) were immediately transferred while 83 (39.7%) of the patients were hospitalised in the rural level 2 trauma centre for observation. Two (2.4%) failed the intent to treat locally. One patient, suffering from multi-trauma, was stabilised after damage control laparotomy only to succumb to an enlarging epidural haematoma. Another patient was transferred 2 days after admission because of difficulty in clinical evaluation due to a previously existing neurological disorder, but no active treatment was necessary. All other 81 patients recovered uneventfully. Selective head injured patients with pathological CT scan may be safely managed in level 2 trauma centres. A committed trauma team in the rural trauma centre, neurosurgical consultation and availability of a teleradiology system are requisites. Currently existing transfer criteria should be carefully re-evaluated.Emergency Medicine Journal 09/2007; 24(8):550-2. · 1.44 Impact Factor -
Article: Is routine portable pelvic X-ray in stable multiple trauma patients always justified in a high technology era?
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ABSTRACT: According to the Advanced Trauma Life Support, portable pelvis radiography (PXR) is mandatory in multiple trauma patients, and is performed following initial clinical evaluation. The purpose of an early PXR is to identify pelvic fractures that may have haemodynamic consequences. Today, ultrafast multi-detector CT scanners (MDCT) are readily available and widely used in the evaluation of stable trauma patients. The objective of this study was to determine the impact of PXR in stable blunt multiple trauma patients, who required CT scan for full evaluation of the abdomen and pelvis. A retrospective review of all stable blunt trauma patients, suffering from pelvic fractures was performed from January 2001 until December 2004 at two high volume Trauma Centres. Patients' demographics and Injury Severity Scores (ISS) were abstracted from our trauma registry. Two certified radiologists and two certified orthopaedic surgeons retrospectively evaluated and compared PXR films and CT angiographies (CTA) of the abdomen and pelvis. We recorded each case when the management policy was altered due to the results of imaging and compared the clinical impact of both modalities. One hundred and twenty-nine stable blunt multiple trauma patients with pelvic fractures underwent CTA of the abdomen and pelvis during their initial evaluation. Mean ISS was 16.5. Average Glasgow Coma Scale on arrival was 13.2 (range 3-15). Compared to CTA, sensitivity and specificity of the PXR was 64.4 and 90.0%, respectively. CTA diagnosed 35.6% more pelvic fractures than PXR (p<0.05). No changes in the therapeutic policy were observed following PXR results. In 19 (14.7%) patients, CTA findings led to pelvic angiography. PXR in stable blunt multiple trauma patients did not change the therapeutic policy in our patients. CTA of the abdomen and pelvis is the imaging modality of choice in blunt multiple trauma, regardless of the findings of PXR. Benefit of routine PXR is questionable in hospitals where MDCT is available. Based on our results, we suggest re-evaluating the current practice of routine mandatory portable pelvis radiography.Injury 06/2007; 38(5):559-63. · 1.98 Impact Factor -
Article: Total pulmonectomy in trauma: a still unresolved problem--our experience and review of the literature.
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ABSTRACT: Emergency pneumonectomy for trauma is associated with very high mortality. Despite significant improvement of the intensive care resources, results of this procedure have not been improved during the last 20 years. When performed because of hemorrhagic shock, pneumonectomy is almost always fatal. We present a series of four patients who underwent total pneumonectomy in our trauma center. The main purpose of this study was to describe pathophysiologic changes and to discuss possible therapeutic alternatives based on the literature review after this operation.The American surgeon 05/2007; 73(4):381-4. · 1.28 Impact Factor -
Article: Management of victims in a mass casualty incident caused by a terrorist bombing: treatment algorithms for stable, unstable, and in extremis victims.
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ABSTRACT: Bombs aimed at civilian populations are the most common weapon used by terrorists throughout the world. Over the last decade, we have been involved in the management of more than 20 mass casualty incidents, most of which were caused by terrorist bombings. Commonly, in these events, there may be many victims and many deaths. However, only a few of the survivors will suffer from life-threatening injuries. Appropriate and timely treatment may impact their survival. Due to the complex mechanism of injury seen in these scenarios, treatment of victims injured by explosions is somewhat different from that exercised in blunt and penetrating trauma from other causes. The intention of this article was to outline the initial medical treatment of the injured victim arriving at the emergency department during a mass casualty incident caused by a terrorist bombing. Treatment protocols for stable, unstable, and in extremis patients are presented.Military medicine 01/2007; 171(12):1155-62. · 0.92 Impact Factor -
Article: New technique of direct intra-abdominal pressure measurement.
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ABSTRACT: To determine the efficacy of 14-Fr PVC round drain in the direct measurement of intra-abdominal pressure. Fifty consecutive patients undergoing elective laparoscopic surgery in a tertiary teaching hospital were included in this pilot study. Patients underwent laparoscopic cholecystectomy, appendectomy, splenectomy, colectomy and Nissen fundoplication. After creation of pneumoperitoneum and insertion of the trocars as indicated by the operation, a 14-Fr PVC round drain was inserted into the abdominal cavity via one of the laparoscopic ports. It was then connected under sterile conditions to the invasive blood pressure measurement system. Intra-abdominal pressure was gradually increased. Intra-abdominal pressures as measured through the round PVC drain were compared to those measured by the laparoscopic insufflator at 5, 8, 12 and 24 mmHg. Two hundred measurements using each of the two methods were performed and correlated. The correlation coefficient was 0.996. No complications were observed with this new technique. Direct measurement of intra-abdominal pressure using 14-Fr PVC round drain is a newly described technique that is simple, fast and credible. Future investigation will be needed to confirm the reliability of this method during postoperative follow-up of intra-abdominal pressures in selected patients.Asian Journal of Surgery 11/2006; 29(4):247-50. · 0.57 Impact Factor -
Article: A new technique of direct intra-abdominal pressure measurement: a preliminary study.
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ABSTRACT: The purpose of this study was to determine if a 14-F polyvinyl chloride (PVC) round drain is a reliable tool for direct intra-abdominal pressure measurement. A prospective interventional study. Department of Surgery B, intensive care unit, recovery room, Hillel-Yaffe level II trauma center. Forty patients undergoing abdominal surgery and treated postoperatively with intraperitoneal drains and intravesical catheters were included in this study. The indication for insertion of intraperitoneal drains and intravesical catheters was strictly medical. The decision of placing urinary bladder catheter and PVC round drain was done by a senior surgeon. Intra-abdominal pressures were measured simultaneously through the intraperitoneal drain and the urinary catheter. Using a sterile technique, the intraperitoneal drain was disconnected from the drainage bulb and connected to an invasive blood pressure monitoring system. Intravesical pressures were measured by inserting 50 mL into the bladder, and then the urinary catheter was connected to an invasive blood monitoring system. Measurements were done twice a day for 3 days or less if earlier removal of either the intraperitoneal drain or urinary catheters were medically indicated. Two hundred twenty-even simultaneous measurements were performed. Pressures as measured through the intraperitoneal drain were found to be significantly correlated to pressures as measured intravesically (r = 0.962). Direct measurement of the intra-abdominal pressure via a 14-F PVC round drain is a newly described technique. Our method is simple, safe, and credible. Future investigation is needed to confirm the reliability of this method for continuous postoperative measurement of the intra-abdominal pressure in selected patients.The American Journal of Surgery 03/2006; 191(2):235-7. · 2.78 Impact Factor -
Article: Burkitt's lymphoma: an unusual cause of obstructive jaundice.
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ABSTRACT: Biliary obstruction secondary to malignancy is a common clinical problem. Rarely, biliary obstruction is due to non-Hodgkin's lymphoma. Obstructive jaundice in these patients usually presents late in the course of the disease. Burkitt's lymphoma is a subtype of non-Hodgkin's lymphoma. Unlike other forms of non-Hodgkin's lymphoma, Burkitt's lymphoma presents as an extranodal disease. We present the case of a patient suffering from non-endemic Burkitt's lymphoma whose initial presenting symptom was obstructive jaundice.Asian Journal of Surgery 11/2005; 28(4):301-4. · 0.57 Impact Factor -
Article: Blast injuries.
New England Journal of Medicine 07/2005; 352(25):2651-3; author reply 2651-3. · 53.30 Impact Factor -
Article: Sternal Fracture Should Prompt the Evaluation of the Entire Spine in Trauma Patients
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ABSTRACT: Background and Purpose: Sternal fracture has traditionally been considered an indicator of a severe mechanism of trauma, which warrants careful evaluation of the patient for accompanying injuries. The purpose of this study is to determine the incidence, distribution and mechanisms of spinal fractures associated with fractures of the sternum. Material and Methods: Trauma registry data, medical records and X-rays of all patients admitted to the Trauma Unit at Hillel-Yaffe Medical Center, Hadera, Israel, with a diagnosis of sternal fracture during a 6-year period, between January 1, 1997 and December 31, 2002, were reviewed retrospectively. Results: 147 patients with sternal fracture were eligible for analysis. The combination of spinal fracture in association with sternal fracture was found in 19 patients (13%), ten males (52.7%) and nine females (47.3%). Mean age was 49 years and mean Injury Severity Score (ISS) 18.6. Motor vehicle accidents were the most common cause of these fractures. An unusually high proportion of cervical spine fractures (36.8%) was noted. Three of the 19 patients (15.5%) with sternal and spinal fractures also suffered from cardiac contusion, confirmed by an elevation of the MB fraction of creatine phosphokinase, ECG changes, and regional hypokinetic areas on echocardiography. Conclusion: Recent studies indicate that the incidence of sternal fracture has risen while its association with accompanying serious injuries has lessened. This is most likely due to the increased use of seat belts in motor vehicle accidents. In both theory and practice spinal fracture is an associated injury in cases of sternal fracture, and usually involves the thoracic level. The authors describe an almost equal distribution of the level of spinal injury, with an unusually high proportion of cervical involvement. They also found a high incidence of myocardial contusion among patients with combined sternal and spinal fractures. Therefore, X-ray evaluation of the entire spine in patients suffering from a fractured sternum, and closer cardiac monitoring of patients with both sternal and spinal fractures are recommended.European Journal of Trauma 01/2005; 31(1):57-60. -
Article: Temporary bowel diversion using the Bogotá bag (Hadera stoma): technical details.
Journal of the American College of Surgeons 09/2004; 199(2):344-6. · 4.55 Impact Factor -
Article: Prehospital management of earthquake casualties buried under rubble.
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ABSTRACT: Earthquakes continue to exact a heavy toll on life, injury, and loss of property. Survival of casualties extricated from under the rubble depends upon early medical interventions by emergency teams on site. The objective of this paper is to review the pertinent literature and to analyze the information as a practical guideline for the medical management of casualties accidentally buried alive.Prehospital and disaster medicine: the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation 20(2):122-33. -
Article: Precision of in-hospital triage in mass-casualty incidents after terror attacks.
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ABSTRACT: Proper management of mass-casualty incidents (MCIs) relies on triage as a critical component of the disaster plan. [corrected] The objective of this study was to assess the precision of triage in mass-casualty incidents. The precision of decisions made by two experienced triage officers was examined in two large MCIs. These decisions were compared to the real severity of injury as defined by the Israeli Defence Forces (IDF) classification of severity of injuries and the Injury Severity Score (ISS). Two experienced trauma physicians triaged a total of 94 casualties into 77 mild, seven moderate, and 10 severe casualties. Based on the IDF criteria, there were 74 mild, five moderate, and 15 severe casualties. Based on ISS scoring, there were 78 mild (ISS <9), five moderate (9 < or = ISS < 16), and 11 severe (ISS <16) casualties. Of 15 severely injured victims defined by the IDF classification of injury severity, the triage officers identified only seven (47%). Primary triage, even when carried out by experienced trauma physicians, can be unreliable in a MCI.Prehospital and disaster medicine: the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation 21(1):20-3. -
Article: Defining the problem, main objective, and strategies of medical management in mass-casualty incidents caused by terrorist events.
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ABSTRACT: Based on the experience of managing > 20 such events during the last decade, the authors' understanding of a mass-casualty incident is that it is an event in which there may be many victims, but only a few that actually suffer from life-threatening injuries. To make an impact on survival, one must identify those who are severely wounded as quickly as possible and offer those patients optimal care. Experienced trauma physicians are the most important resource available to achieve this objective, and they should be allocated to the treatment of seriously injured victims instead of more traditional management roles such as triage and incident manager.Prehospital and disaster medicine: the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation 23(1):82-9. -
Article: Inadequate mass-casualty knowledge base adversely affects treatment decisions by trauma care providers: Survey on hospital response following a terrorist bombing.
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ABSTRACT: Healthcare professionals require a unique knowledge base to function effectively during a hospital's response to a mass-casualty incident (MCI). A survey of 128 physicians, nurses, and emergency medical technicians involved in trauma care was conducted to assess their knowledge base and how it affected their decision-making in response to a MCI following a terrorist bombing. Three-quarters of the study group responded that = or >20% of the surviving victims were critically injured. Only half of the responders indicated that the main objective of medical management is identifying and treating patients with critical injuries. Forty percent of responders indicated that they would not triage a critically injured victim to immediate care. This survey indicates that further education in the principles of MCI management should be based on critical evaluation of the literature.Prehospital and disaster medicine: the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation 24(4):342-7.
Top co-authors
Top Journals
Institutions
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2011
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Shaare Zedek Medical Center
- Department of Surgery
Jerusalem, Jerusalem District, Israel
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2005–2009
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Hillel Yaffe Medical Center
H̱adera, Haifa District, Israel
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