Publications
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.
 
Glaucoma, the third leading cause of blindness in the western world, is characterized by painless, gradual loss of visual fields which may lead to severe visual impairment or even blindness. In 4 years of operation of a mobile glaucoma unit for screening and early diagnosis of glaucoma, 10,037 subjects aged 18-95 years were screened (4504 women, 45%); 55% were under 50 years (Graph 1). Ocular hypertension was diagnosed in 8.0%; primary open angle glaucoma (POAG) in 0.8%, with 2/3 already under treatment, the rest newly diagnosed. Pseudo-exfoliative glaucoma was diagnosed in 0.2%; only 2 cases had closed angle glaucoma; 91% of those screened were normal (Fig. 4; age stratification, Graph 3). POAG increased with age, from 0.2% in those under 40 years to 10% in those over 80; POAG was more common in men, but OHT was similar in both sexes (6.0% vs. 5.3%). There was no correlation between incidence of POAG and place of work except in the Sorek Nuclear Center (1.9% vs. 0.8%, p = 0.11). Other conditions significantly more frequent in POAG than normals were diabetes mellitus (x 2.5), systemic hypertension (x 4), myopia (x 2) and history of intraocular surgery (x 6).
 
Over the past 15 years, percutaneous therapeutic cardiac catheterization has become increasingly important in the treatment of congenital heart disease. We describe our experience in 1000 such catheterizations between 1993-1997. 55% were in 1-12-year-olds; only 20% were in patients younger than 1 year old and 11.3% were in adults with congenital heart defects. In about 50% it was at least a second cardiac catheterization. Overall, there were 425 therapeutic cardiac catheterizations, increasing from 33% in the first 200 procedures, to 63% in the last 200. We performed 30 different types of therapeutic catheterizations: 23.3% were valvular dilations, 21.4% vessel angioplasties, 36.9% closure procedures, 9.2% electrophysiological procedures, and 9.2% miscellaneous. In 31.3% of therapeutic catheterizations we used 12 new procedures. Minor complications occurred in 8.5% and major in 0.6%; most complications were successfully treated or were self-limited and there was no residual damage. In this report the current role of each type of major catheterization is discussed on the basis of our experience. Further development of technology for lesions not amenable to currently available transcatheter methods, and longer follow-up for current techniques will consolidate the role of therapeutic cardiac catheterization in congenital heart disease.
 
The Israeli Society for Clinical Oncology and Radiotherapy appointed experts in breast cancer therapy to assess the Society's policy regarding hormone replacement therapy (HRT) in breast cancer survivors with menopausal symptoms. The first policy letter was published in November 2002, and referred to available literature at that time which included retrospective data alone. The professional literature suggested no increased risk in breast cancer recurrence or cancer specific mortality, and no effect on overall survival with the use of HRT for a limited period (up to 3 years). This data served as the rationale for international prospective studies. Former committee recommendations and precautions are detailed in the original publication. In February 2004, the interim analysis of a prospective trial, the HABIT (Hormonal replacement therapy after breast cancer--is it safe?) was published. In that trial, breast cancer survivors with menopausal symptoms were randomized to HRT (estrogens with or without progestins) or no therapy for 2 years. A total of 434 women were recruited from centers in Scandinavia who participated with the International Breast Cancer and the European Organization for Research and Treatment groups. Analysis was restricted to 345 women with at least one follow up report; median follow-up period was 2.1 years. The relative risk for breast cancer event was 3.5 (95% C.I. 1.5-8.1) in HRT users as compared with the non-HRT group and the HABIT trial was terminated. Study limitations are discussed. Thereby, at this time HRT can no longer be considered safe in breast cancer survivors. Physicians treating breast cancer survivors for severe menopausal symptoms should present study results and alternative non-hormonal treatment options to allow patients optimized consented treatment decisions.
 
The occurrence of cancer in both members of 105 couples related only by marriage, is reported from a regional hospital, 68 couples had tumors of the same histopathologic type. 6 had tumors of the same organ, with similar histology. The tumors were of the brain (astrocytoma), urinary bladder (transitional cell carcinoma) lung (adenocarcinoma), retroperitoneum (sarcoma), stomach (adenocarcinoma) and colon (adenocarcinoma). The significance of our observations is unclear, and they are most probably coincidences. Analysis of more data could help to explain these observations, because factors such as environment, nutrition and contamination affect both members of a married couple for extended periods of time.
 
Infection with Echovirus 11 is mostly asymptomatic, but it may cause a wide variety of clinical diseases, from gastroenteritis to serious diseases such as meningitis and myocarditis. In small infants, especially during the first days of life, echovirus infection may appear as a sepsis-like illness, and cause disseminated intravascular coagulopathy and shock. We present 2 infants with severe Echovirus 11 infections. A 3.5-month-old died within 24 hours of shock and probably myocarditis. The other, 6-days old, presented with meningitis, hepatitis and disseminated intravascular coagulopathy. It recovered after treatment with intravenous immunoglobulin. Echovirus 11 may cause life-threatening infections in small infants. Pediatricians should be alert to the special characteristics of this disease.
 
To study the use of FISH analysis for detecting the presence of numerical alterations of chromosomes 11 and 17 combined with cytology in exfoliated cells from voided urine as a method for diagnosis and follow-up in patients with urothelial carcinoma (UC) of the bladder. During the period April 2005 till June 2006, three groups were studied. The first group included 15 patients without UC. The second group included 25 patients undergoing evaluation for suspected UC. The third group included 25 patients enrolled in cystoscopy follow-up for previous UC. All the patients underwent cystoscopy, cytologic examination and FISH analysis for centromeric probes 11 and 17 performed on voided urine. After diagnosing the bladder UC, the tumor was staged and graded according to the pathologic findings. The sensitivity and specificity of FISH and Cytology were assessed. Data were analyzed with t-test when comparing two groups, and using ANOVA test when comparing more than two groups. These statistical analyses were executed with statistical software PRISM version 4.03. The sensitivity of FISH when using the centromeric probes of chromosomes 11 and 17 was 95.2%. The specificity was approximately 94.4%. The monosomy, trisomy, and polysomy in the patients with UC were 95.2%, 78.6% and 35.7% (p < 0.05) respectively. FISH was positive in 92.3% (24/26) in low grade tumors and in 100% (16/16) in high grade tumors (p > 0.05). The sensitivity of cytology was 31%. The cytology was positive in 23% (6/26) in low grade tumors and in 43.8% (7/16) in high grade tumors (p < 0.05). FISH analysis using centromeric probes of chromosomes 11 and 17 is an effective noninvasive method for the detection of altered chromosome numbers in bladder cancer cells in urine exfoliated cells. The sensitivity of FISH is higher than that of cytology in detecting UC. The combined analysis of FISH and cytology, does improve the accuracy of cytology but does not improve the specificity. Monosomy is the most prevalent numerical aberration found in patients with UC of the bladder. FISH analysis might give better results especially when cytology is negative. This method may help to decrease the frequency of cystoscopies in the follow-up of patients with confirmed bladder UC. Using multi-probe FISH test may improve the sensitivity. However, further studies are needed to confirm our results and conclusions.
 
A summary of 80 fatal cases among 1200 burn patients hospitalized between 1950 and 1970 is presented. 18 of the cases died of respiratory damage. The percentage of such fatalities has been rising in the past decade. This is in contrast to the lower proportion of deaths due to infection, most probably because of the use of topical agents such as silver nitrate, Sulfamyelon and silver sulfadiazine. Hypovolemic shock as a cause of death belongs to the past: 11 of 12 such cases died before 1962. The fact that sepsis as a cause of death has gradually increased is due to longer survival with modern treatments. The same applies to renal complications.
 
We present and review a single center experience with laparoscopic renal surgery for renal cancer including laparoscopic radical and partial nephrectomy. During the period September 2002 - January 2005, 180 patients underwent laparoscopic renal surgery at our center for several indications. A total of 121 patients underwent radical nephrectomy (76) or partial nephrectomy (45) for solid renal tumors. Their data was recorded and analyzed including age, indication for surgery, operative time, blood loss, intra- and postoperative complications, conversion rates, histological results and outpatient follow-up. The mean age at surgery was 65 years (range: 21-89 years). The indications for surgery were solid, enhancing renal masses. For tumors larger than 4 cm, a radical nephrectomy was performed. Tumors that were smaller than 4 cm were removed by partial nephrectomy. The mean operative time was minutes (range: 70-280 minutes) and the mean blood loss was 220 cc (range: 30-700 cc). The mean blood loss was significantly lower in the radical nephrectomy group (120 cc) than in the partial nephrectomy group (320 cc). In eight patients major intraoperative complications were noted including injury of the hilar vessels (5 cases), inferior vena cava (1 case), large bowel and spleen (one patient) and duodenum (1 case). Conversion to open surgery was needed in nine patients (7.4%), four in the radical nephrectomy and five in the partial nephrectomy group. Major postoperative complications were recorded in two patients who underwent radical nephrectomy (pneumothorax and incarcerated inguinal hernia) and in two patients who underwent partial nephrectomy (urine leakage). The pathological examination demonstrated renal cell carcinoma in 109 cases, oncocytoma in 6 cases, angiomyolipoma in 2 cases, sarcoma of the kidney and metastasis from lung cancer in one case each and a hemorrhagic cyst in one case. In all patients who underwent radical nephrectomy negative surgical margins were obtained, in three patients after partial nephrectomy the surgical margins were focally involved by tumor. The mean tumor size was 5.1 cm and 3.1 cm after radical or partial nephrectomy respectively. During follow-up, none of the patients developed local or distant recurrence. The laparoscopic approach to kidney cancer seems to be safe and oncologically sound. The low morbidity rate together with the inherent advantages of laparoscopic surgery make this approach attractive and we believe it should be considered the new standard of care for renal cancer.
 
In 59 women with epithelial ovarian cancer serum CA 125 was determined and they were then followed for 3 years. In those with active disease, mean serum CA 125 (289 units/ml) and positivity rate (85%) were significantly higher than in those without evidence of disease (44 units/ml and 17%, p = 0.001 and p < 0.001, respectively). Actuarial 3-year survival curves were calculated according to CA 125 serum level. 91% of those with CA 125 lower than 35 units/ml survived 3 years, as compared to 40% of those with CA 125 levels higher than 35 units/ml (p < 0.01). In ovarian cancer CA 125 serum level correlates with the state of the disease and can be used in the prediction of 3-year survival.
 
Unlabelled: A 64-year-old woman was diagnosed as suffering from ovarian cancer. At that time, in 1984, she was treated with chemotherapy and complete remission was achieved. The disease recurred 2.5 years later and chemotherapy was delivered again. The patient remained disease free for 9 years. At that point a routine blood examination revealed a high serum level of the marker CA-125. A second recurrence of ovarian cancer was assumed. Nonetheless, work up revealed that the rise in CA-125 was related to the presence of a non-Hodgkins lymphoma (NHL). Conclusions: This case together with our review of the literature highlights the emerging roll of the CA-125 marker in the diagnosis and follow-up of non-Hodgkins lymphoma. Our case also illustrates that physicians should be aware of the fact that markers may be misleading.
 
Major hepatic resections have been associated with significant morbidity and mortality. In the past decade or so this has changed and such procedures are now done in increasing numbers. In the past 5 years we operated on 129 patients with benign or malignant hepatic lesions (75 females, 54 males; age-range 14-84). The reason for surgery was malignancy in 94 (72.9%) and benign lesions in 35 (27.1%). The most common indication for surgery was liver metastases secondary to colorectal cancer in 45% of all patients or 61.7% of those operated for malignancy. Primary liver cancer was the cause for liver resection in 13.2% of all patients or 18.1% for those with malignancy. Of the 35 patients with benign lesions the leading causes for surgery included: giant cavernous hemangioma, simple liver cysts, echinococcus cysts and focal nodular hyperplasia (11%, 22.8%, 20% and 14.3%, respectively). 76 patients underwent anatomical resection and 63 had either a nonanatomical resection or a different operation. Among the former the most common procedure was right hepatectomy (36) and among the later a nonanatomical resection equal to 1-3 Couinod segments (44). Operating time ranged from 55 min. to 8:41 hours with a mean of 3:31 +/- 1:37. Mean hospital stay was 8.7 +/- 5.8 days and 86.8% received between 0-2 units of blood. Overall mortality was 6.2% and 31.2% of the fatalities had cirrhosis. Overall mortality in noncirrhotic patients was 2.6%. The complication rate was 16.3% and only 7 patients (4.4%) were hospitalized in the intensive care unit. This indicates that major liver resections can be done safely, with morbidity and mortality similar to that of other major abdominal operations.
 
Intussusception is a relatively common pediatric emergency. The accepted treatment is closed reduction using barium or air enema and surgery when it has failed. We present our 13-year experience using air enema for treatment of intussusception, emphasizing the reduction with repeated delayed air enema. Between February 1990 and December 2002, air enema procedures were performed in pediatric patients in cases with suspected intussusception. Prior to the procedure, all patients were sedated with meperidine hydrochloride (0.5 mg/kg) or morphine (0.1 mg/kg). Before 1993, surgery was performed after the first ineffective attempt of air enema reduction. Since 1993, in the case of failure of the first attempt, two additional trials of air reduction were performed at an interval of 45-60 minutes prior to surgery. A total of 225 air enema procedures were performed in 201 children (129 males, aged 10.4 +/- 9.1 months, range 8-63 months) with suspicion of intussusception. The diagnosis was confirmed in 148 (66%) out of the 225 procedures performed. A successful reduction of intussusception (by one attempt or more) was achieved in 125 (86%) out of the 148 procedures with proved intussusception. Twenty-one (14%) patients were operated on after the failure of closed reduction. Spontaneous reduction was demonstrated under fluoroscopy in two (0.8%) studies. No complications of the air enema were noted. During 1990-1993, a single reduction attempt of the intussusception by air enema was performed. Successful reduction during this period was achieved in 19 (70%) out of 27 patients and 8 (30%) children were operated on. During the period 1993-2002, we used repeated delayed attempts to obtain reduction of intussusception among 174 patients. The success rate was 89% (108 out of 121 patients) and only 13 (11%) children were operated on. Air enema is an efficient and safe diagnostic and therapeutic tool for intussusception in the pediatric population.
 
Top-cited authors
Yehuda Shoenfeld
  • Tel Aviv University
Bibiana Chazan
  • Ha'Emek Medical Center
Peretz Lavie
  • Technion - Israel Institute of Technology, Haifa, Israel
Raul Raz
  • CLALIT
Michael Dan
  • Tel Aviv University