Biomedical subjects

A Hallak

Publications and source records attributed to A Hallak.

At least 19 recordsLinked to original sources

PubMed2003

Rofecoxib reduces polyp recurrence in familial polyposis.

The long-term (mean of 16.4 +/- 4.2 months) efficacy and safety of rofecoxib (a specific COX-2 inhibitor) in maintaining the colon free of polyps in familial polyposis patients was assessed. Eight patients were treated with rofecoxib 25 mg every day. Sigmoidoscopy/colonoscopy was performed at study entry and every six months. At each endoscopy the number, size, and histological grade of all polyps were assessed, and the polyps were removed. The drug was well tolerated with no significant adverse events throughout the study. A highly significant reduction in the rate of polyp formation (70-100%) was observed in all patients from a mean number of 15.1 +/- 11.7 at baseline to 6.0 +/- 5.8 at one year and 1.6 +/- 1.6 at the end of follow-up (P = 0.016 and 0.008, respectively). No patient developed cancer or high-grade adenoma. In conclusion, Long-term use of rofecoxib is well tolerated and effective in inhibiting polyp formation in polyposis patients.

Adenomatous Polyposis Coli↗

PubMed2001

Proton pump inhibitors reduce cell cycle abnormalities in Barrett's esophagus.

Neoplastic progression in Barrett's esophagus is a multi-step process in which the metaplastic columnar epithelium sequentially evolves through a metaplasia-dysplasia-carcinoma sequence. The expression and DNA copy number of key cell cycle regulatory genes in paired normal and Barrett's esophagus samples was evaluated. Protein levels were evaluated in 60 formalin-fixed, paraffin-embedded human tissues by immunohistochemistry. DNA copy number from 20 fresh tissue pairs was analysed by Southern blot analysis. All normal mucosal samples expressed the p27(kip1) protein, but did not display appreciable nuclear staining for p16(kip4), p21(cip1) or cyclins D1 and E. Barrett's metaplastic specimens displayed increased expression levels of p16(kip4) (74%), p21(cip1) (89%) and cyclins D1 (43%) and E (37%). p27 protein was absent in three cases. There was a significant correlation between the expression of p16(kip4) and cyclin E, and p21(cip1) and p27(kip4) with cyclin D1. DNA analysis did not reveal any amplification or deletion of these genes. Acid suppression, however, was associated with significantly lower expression levels of key cell cycle proteins. Increased expression of key cell cycle regulatory genes appears to occur early in the neoplastic progression associated with Barrett's esophagus. Treatment with proton pump inhibitors appears to alter this increased expression.

Adult↗

PubMed2001

Low-dose low-molecular weight heparin (enoxaparin) is effective as adjuvant treatment in active ulcerative colitis: an open trial.

Ulcerative colitis is a chronic inflammatory bowel disorder of unknown etiology. Treatment of flare-ups is based on mesalamine and steroids. Treatment of moderate to severe ulcerative colitis with high-dose heparin and low-molecular-weight heparin was reported. The mechanism was assumed to be a combination of anti-coagulant and anti-inflammatory effects. Low-molecular-weight heparin is better and safer than unfractionated heparin. Studies of low-dose low-molecular-weight heparin in experimental models of inflammation and in inflammatory diseases demonstrated a beneficial effect. Our aim in this study was to evaluate the effect of low-dose, low-molecular-weight heparin in active ulcerative colitis. Twelve patients with flare-ups of colitis were prospectively enrolled. Subcutaneous injections of 5-mg enoxaparin were administered at weekly intervals for 12 weeks. Mesalamine doses remained unchanged. Clinical, laboratory, endoscopic, histologic, and quality-of-life scores were evaluated at the beginning and end of the study. Ten patients completed the study. Mean age was 40.1; the female-male ratio was 7:3. Mean Mayo scores were 9.0 +/- 0.94 at baseline and 3.4 +/- 2.0 at the end of the study (P = 0.0001). Endoscopic scores decreased from 2.2 +/- 0.4 to 1.2 +/- 1.0 (P = 0.049) and in 7 of 10 patients extent of disease shortened. A significant increase in IBDQL scores from 135.7 +/- 37.17 to 179.6 +/- 45.15 points was demonstrated (P = 0.0117). Adverse events were one hospitalization due to abdominal pain, arthralgia (1), transient peripheral edema (1), and elevation of alkaline phosphatase (1). During follow-up, one patient required colectomy and another experienced an exacerbation. In conclusion, low-dose low-molecular-weight heparin once a week, combined with mesalamine, may be an effective therapy for active ulcerative colitis. It may delay or preclude the need for steroid treatment. Controlled studies to evaluate efficacy are needed.

Adult↗

PubMed2001

[Treatment of Crohn's disease with anti TNF alpha antibodies--the experience in the Tel Aviv Medical Center].

TNF alpha is a pro-inflammatory cytokine in Crohn's disease and it's neutralization is beneficial in patients with active disease. Remicade is a chimeric monoclonal anti-TNF antibody. Remicade is used in our center since December 1998 in 13 patients who were treated for active disease or fistula. We followed the patients and treatment results in order to estimate the efficacy and safety of this preparation. Response to treatment was measured by the Crohn's Disease Activity Index (CDAI) in patients treated due to active disease, or by the presence of discharge from external fistulae. Five out of seven patients with fistulae had less or no discharge after completing a course of 3 infusions. Four out of 6 patients treated due to active disease improved significantly after a single infusion. Five out of the six needed additional injections due to symptom recurrence. Intervals between infusions were 2 weeks--for fistulae patients to 32 weeks for patients with active disease. Adverse events for the 13 patients were usually mild except for 4 patients that suffered from anaphylactic shock, disseminated eruption (2) and eosinophilic pneumonitis. In summary, treatment of patients with active Crohn's disease or fistulae with monoclonal anti-TNF antibodies is an effective and relatively safe option after established treatment has failed. Analyzing the results of on going clinical trials and of the patients treated off-protocol will enable to establish new treatment strategies for patients with active Crohn's disease and fistulae.

Adolescent↗

PubMed1998

Major vascular injuries during laparoscopic cholecystectomy. An institutional review of experience with 2589 procedures and literature review.

BACKGROUND: Since the introduction of laparoscopic cholecystectomy, major vascular injury has been a rare but very serious complication of the procedure. METHODS: All 2,589 laparoscopic cholecystectomies performed at our institution between May 1, 1990, and December 31, 1996, were retrospectively reviewed to identify major vascular injury and the mechanisms involved. All these procedures were performed either by surgical attendings or senior surgical residents. RESULTS: During the 1,372 operations performed here between May 1, 1990, and May 1, 1994, there were three major vascular injuries. One was to a portal vein, due to dissection during lysis of adhesions; the other two, to the aorta and vena cava, were due to trocar insertions. There was one mortality secondary to liver failure following repair of the portal vein injury. Between May 1, 1994, and December 1, 1996, there were no major vascular injuries; our overall incidence was 0.11%. A review of the literature on this subject is included. CONCLUSIONS: Laparoscopic cholecystectomy is a very safe procedure; major vascular injury is a rare complication, but mandates early recognition and consideration of prompt exploratory laparotomy. These injuries can be avoided by strict adherence to laparoscopic guidelines: obtaining pneumoperitoneum by the open technique, inserting side trocars under direct vision, elevating the abdominal wall prior to trocar insertion, and training surgeons in a laparoscopic laboratory.

Aged↗

PubMed1998

Endoscopic extraperitoneal herniorrhaphy. A 5-year experience.

BACKGROUND: This report reviews our experience with 512 groin hernias treated by a laparoscopic extraperitoneal approach over the past 5 years. We detail the modifications that have been made to this procedure and compare our morbidity and recurrence rates with other laparoscopic and open herniorrhaphy techniques. METHODS: Between September 1991 and September 1996, 395 male patients underwent 512 hernia repairs by an endoscopic total extraperitoneal approach (TEP). Their ages ranged from 18 to 82 years. There were 267 indirect, 218 direct, 17 pantaloon, and 10 femoral hernias. Of these, 117 were bilateral and 54 were recurrent. All repairs were done with polypropylene mesh. All patients were given general anesthesia except 16 (4.05%) who had epidural anesthesia. RESULTS: Of 512 hernia repairs, seven required conversion to an open procedure (1.3%). There were 19 complications (4.8%), including eight cases of urinary retention, six of groin collection, one bladder injury, one trocar site infection, one transient neuralgia, one cardiac arrhythmia, and one laryngospasm. Follow-up on 354 patients (41 were lost to follow-up) ranged from 6 to 66 months (mean, 38). There were six hernia recurrences (1.69%), but no deaths. Operative time ranged from 15 to 185 min. CONCLUSIONS: The endoscopic extraperitoneal approach to groin hernia repair has a recurrence rate comparable with open and other laparoscopic techniques. Operative time has decreased considerably with experience. Familiarity with the technique has eliminated the need for balloon dissectors, cauteries, suction irrigation, Foley catheters, and stapling of the mesh. These advances, along with shortening of the operative time and employment of reusable trocars, have permitted a significant decrease in the cost of the procedure. This study provides the longest follow-up reported with this technique. In experienced hands, the TEP repair produces results that are comparable with the open, tension-free repair and represents a reasonable alternative.

Adolescent↗

PubMed1998

Laparoscopic herniorrhaphy: review of complications and recurrence.

Laparoscopic hernia repair has evolved considerably since its introduction. Different methods have been described, and multiple studies have been performed reporting widely varying outcomes. This study was undertaken to review all the major publications on laparoscopic herniorrhaphy from 1993 to 1996 and evaluate the rates of recurrence and complications involved in the various techniques. In a total of 11,222 laparoscopic hernia repairs, the procedure performed most frequently was the transabdominal preperitoneal patch (TAPP), followed by the total extraperitoneal patch (TEP). There were 300 (2.7%) recurrences. From 9,955 hernia repairs, there were 1,534 (15.4%) complications. Hematoma/seroma (456), neuralgia (199), urinary retention (150), and chronic pain (39) were the most frequently reported complications. Laparoscopic herniorrhaphy is a higher effective method of hernia repair with results comparable with the open technique. TAPP is still the most widely performed technique. TEP is becoming more popular, mainly because of its excellent outcome. The major drawback of TEP is the difficulty of reproducibility by different general surgeons with comparable results. Other techniques such as plug and patch carry a high rate of recurrence and complications and should probably be completely abandoned.

Herniorrhaphy↗

PubMed1997

A simplified approach to laparoscopic fundoplication.

BACKGROUND: There is a certain amount of controversy regarding the need to divide the short gastric vessels (SGV) in laparoscopic fundoplication for treatment of gastroesophageal reflux disease (GERD). In addition, there is often difficulty in identifying the crural fibers when encircling the lower esophagus. METHODS: We determine whether it is necessary to divide the SGV by trying to appose the gastric fundus to the anterior abdominal wall intraoperatively. If this could be done easily, the SGV are preserved. When their division is required, a posterior gastric approach is employed. We have also found that the injection of methylene blue into the left crural fibers anterior to the esophagus is helpful in identifying the left side when dissection posterior to the gastroesophageal junction is difficult. RESULTS: Between 1992 and 1995 we performed 20 laparoscopic fundoplications for GERD. All patients had at least grade 3 esophagitis (Savary-Miller scale), increased esophageal exposure to acid (median DeMeester score of 195), and decreased lower esophageal sphincter (LES) pressure. The median operative time was 175 min. There were no conversions to open surgery, and there was no mortality. Three patients developed transient postoperative dysphagia and one patient had pneumonia. The median hospital stay was 3 days; all patients were free of reflux symptoms at follow-up ranging from 7 to 42 months. CONCLUSION: We conclude that the techniques described by us aid in intraoperative decision making and allow laparoscopic fundoplication to be both simple and effective.

Adult↗

PubMed1997

Laparoscopic staging of Hodgkin's disease.

With recent advances in laparoscopy, specifically the development of laparoscopic splenectomy, a complete laparoscopic Hodgkin's staging procedure is now possible. Using five trocars and the patient in the right semidecubitus position, six laparoscopic staging procedures were performed. All were stages IIA or IIB pre-operatively, and none were upgraded to stage III or IV as a result of the procedure. Operative time was from 185-255 min. (mean 210 min.) There were no operative morbidities or mortalities associated with the procedure. We believe this procedure will be adopted by more surgeons as they become more comfortable in performing laparoscopic splenectomies.

Biopsy↗

PubMed1997

Pre-illness dietary factors in inflammatory bowel disease.

BACKGROUND: The effect of environmental factors has been demonstrated in the pathogenesis of inflammatory bowel disease (IBD). Nutrition may be one of them. AIM: To investigate the pre-illness diet in patients with recent IBD in comparison with matched population and clinic controls. METHODS: Quantified dietary histories were obtained from 87 patients with recent IBD (54 ulcerative colitis (UC) and 33 Crohn's disease (CD)) and 144 controls. Odds ratios (OR) for IBD were derived for intake levels of various foods. RESULTS: A high sucrose consumption was associated with an increased risk for IBD (OR 2.85 (p = 0.03) against population controls and 5.3 (p = 0.00) against clinic controls). Lactose consumption showed no effect while fructose intake was negatively associated with risk for IBD (NS). Similar trends were noted in UC and CD. A high fat intake was associated with an increased risk for UC; this was particularly marked for animal fat (OR 4.09, p = 0.02) and cholesterol (OR 4.57, p = 0.02). A high intake of fluids (p = 0.04), magnesium (p = 0.04), vitamin C, and fruits (NS) was negatively associated with the risk for IBD, while a positive association was found for retinol (p = 0.01). Most of the findings were similar in UC and CD except for potassium and vegetable consumption which showed a negative association only with risk for CD. CONCLUSIONS: An association was found between pre-illness diet and subsequent development of UC and CD. The effect of dietary components may be primary or modulatory.

Adult↗

PubMed1996

Increased leukocyte adhesiveness/aggregation in patients with inflammatory bowel disease during remission. Further evidence for subclinical inflammation.

PURPOSE: We have used a novel leukocyte adhesiveness/aggregation test (LAAT) to show that many patients with inflammatory bowel disease (IBD) in clinical remission have a subclinical low grade inflammation. METHODS: Included in the study are 500 controls, 96 patients with IBD in remission, and 106 patients in relapse. RESULTS: The percent of aggregated white blood cells detected in the peripheral blood was 5.9 +/- 3.9, 9.1 +/- 5.9, and 18.8 +/- 9.4, respectively. The difference between each group and any other was significant at P < 0.0001. Similar results were obtained when other acute phase reactants like the erythrocyte sedimentation rate, white blood cell count, differential count, and C-reactive protein level were examined. However, in a linear regression analysis, LAAT was the only significant (P < 0.0006) variable that could classify correctly each subject to the appropriate category of control and IBD in remission or relapse. CONCLUSIONS: Identification of patients with IBD in clinical remission who have ongoing inflammation may be of clinical-therapeutic relevance. The LAAT is a simple, rapid, and convenient test. The present study indicates that it is also very sensitive.

Adolescent↗

PubMed1996

Esophageal smooth muscle dysfunction in oculopharyngeal muscular dystrophy.

Oculopharyngeal muscular dystrophy (OPMD) is a rare genetic disorder with late-onset progressive myopathy affecting mainly head and neck striated muscles. It is more common in certain ethnic communities. Dysphagia was usually attributed to the malfunction of striated pharyngeal muscles. We studied a group of Bukharan immigrants affected by this disorder (N = 13). Esophageal studies, including endoscopy, manometry, and scintigraphic emptying were performed. Very low pharyngeal pressures were measured. Upper esophageal pressures (UEP) were in the normal range in eight patients, and above normal in three patients. Four also had low lower esophageal sphincter pressure. Esophageal body peristaltic activity was grossly impaired in all patients: mainly nonpropulsive, simultaneous, retrograde, and failed activity was recorded. Marked retention of isotopic material was demonstrated in all patients studied, usually in the middle and lower parts of the body, ranging from 17 to 100% retention. The dysphagia in OPMD is due not only to dysfunction of pharyngeal and upper esophageal striated muscle, but also has a significant smooth muscle component.

Adult↗

PubMed1996

One week triple therapy with omeprazole, clarithromycin and tinidazole for Helicobacter pylori: differing efficacy in previously treated and untreated patients.

BACKGROUND: Triple therapy with omeprazole, clarithromycin, and tinidazole (OCT) has been found to be highly effective against Helicobacter pylori infection. However, its efficacy as a second line regimen for patients who failed metronidazole-based triple therapy has not been evaluated. AIM: The aim of this study was to evaluate the efficacy of low-dose, short-term OCT therapy in an Israeli population, and to compare results obtained in previously treated and untreated patients. METHODS: Patients with duodenal or gastric ulcers and chronic antral gastritis with H. pylori infection as assessed by rapid urease test and/or 14C urea breath test (14C-UBT), were studied. All patients received omeprazole 20 mg b.d., clarithromycin 250 mg b.d. and tinidazole 500 mg b.d. for 7 days. Eradication was assessed by 14C-UBT 4 weeks after treatment. RESULTS: One hundred and fourty-four patients (M/F = 81/63) were enrolled (mean age 48.1 years, range 12-78). Eradication of H. pylori was significantly different between patients who were initially treated with this regimen (90/94, 96%) and patients who had previously failed to eradicate H. pylori with standard triple therapy (27/50, 54%). Moreover, the eradication rate was significantly decreased in patients with more than one previous failure (9/22, 41%) compared to that in patients with only one failure (18/29, 62%). No other differences such as age, gastric pathology, ethnic origin, smoking habits, or pre-treatment urease activity were found to influence the eradication rate. CONCLUSIONS: One-week low-dose triple therapy with OCT is highly effective as an initial therapy in eradicating H. pylori infection. The efficacy is significantly lower when given as a second line treatment in patients who have previously failed to eradicate H. pylori with bismuth-based standard triple therapy.

Adolescent↗

PubMed1996

Endoscopic extraperitoneal herniorrhaphy in 316 patients.

The posterior approach for groin hernia repair as popularized by Stoppa and Nyhus is one of the most solid repairs available. It requires a larger incision than the anterior approach, which has limited its use to recurrent and bilateral hernias. The endoscopic extraperitoneal herniorrhaphy (EEPH) accomplishes a similar repair via three minute incisions. This study suggests that EEPH is at least as safe and efficient as the open preperitoneal repair. Three hundred sixteen male patients underwent 405 hernia repairs by an endoscopic extraperitoneal approach. Ages ranged from 18 to 82 years old. There were 204 indirect, 182 direct, 13 pantaloon, and six femoral hernias. Eighty-nine were bilateral and 42 were recurrent. All repairs were done using polypropylene mesh. Follow-up has been achieved in 89% of patients and ranged from 7 to 50 months, with a median of 25 months. Seven patients (2.2%) required conversion to an open approach. Five recurrences have developed to date. Complications (5.7%) have included urinary retention, bladder injury, groin and/or scrotal hematoma, trocar site infection, lateral femoral cutaneous nerve neuralgia, and cardiac arrhythmia. Endoscopic extraperitoneal herniorrhaphy may provide an appropriate alternative to other methods of hernia repair when performed by experienced laparoscopists.

Adolescent↗

PubMed1995

Elevated serum iron predicts poor response to interferon treatment in patients with chronic HCV infection.

To date, there are no firm clinical, demographic, biochemical, serologic, or histologic features predicting which patients with chronic hepatitis C are more likely to respond to therapy with interferon-alpha. Serum iron, total iron-binding capacity, transferrin saturation, and ferritin were measured in the fasting state. The amount of stainable iron in liver biopsy specimens was evaluated histochemically as well. All patients received subcutaneous recombinant human IFN-alpha 2a three million units thrice weekly by self-administration. Eleven of 13 (84%) responders had low to normal serum iron levels as compared to one of 26 (4%) nonresponders (P < 0.001). The serum transferrin was similar in both groups, but iron saturation was significantly lower in responders (30 +/- 10%) than in nonresponders (53 +/- 12%) (P< 0.001). Serum ferritin and hepatic iron content were higher in nonresponders (NS). It is suggested that increased serum iron and transferrin saturation blunt the action of interferon, as they have opposite effects on the immune system. Iron overload can thus lead to a poor response to interferon. It remains to be seen whether reducing iron overload will improve the response to interferon therapy.

Chronic Disease↗

PubMed1995

High Helicobacter pylori numbers are associated with low eradication rate after triple therapy.

This study tested the influence of pretreatment bacterial density on the eradication rate of Helicobacter pylori with triple therapy. One hundred and thirty two patients with endoscopically confirmed H pylori positive, duodenal ulcer or antral gastritis were treated with triple therapy (colloidal bismuth/metronidazole/amoxicillin) for two weeks. Pretreatment urease activity was assessed by the 14C-urea breath test (UBT) in all patients. The mean (SD) pretreatment UBT concentration was similar in patients with duodenal ulcers (318.4 (175.0)) and patients with antral gastritis (288.9 (165.5)). Overall eradication of H pylori was achieved in 85 of 132 patients (64.4%), but was significantly different between patients with high, intermediate, or low pretreatment urease activity (37.5%, 69.5%, and 87.8% respectively). The mean post-treatment UBT value of patients in whom eradication failed was in direct correlation with the pretreatment UBT values. In conclusion, bacterial density, as assessed by urease activity, is an important factor in predicting H pylori eradication. It is suggested that the pretreatment UBT has the potential to identify patients who require modification of the standard therapeutic regimen.

Amoxicillin↗

PubMed1995

Increased leucocyte adhesiveness/aggregation is a most useful indicator of disease activity in patients with inflammatory bowel disease.

The aim of the study was to determine the comparative usefulness of inflammatory markers, in evaluating disease activity in patients with inflammatory bowel disease. Disease activity was assessed by the Mayo Clinic score for ulcerative colitis, and Harvey-Bradshaw score for Crohn's disease. Five hundred normal blood donors who had no underlying inflammatory condition served as controls. The erythrocyte sedimentation rate, platelet and white blood cell count, C reactive protein, and the leucocyte adhesiveness/aggregation test (LAAT) were determined in each patient. One hundred and twenty four patients with inflammatory bowel disease were tested while in remission and 128 in relapse. Their mean (SD) per cent of aggregated white blood cells in the peripheral blood was 8 (5) and 17 (10) respectively compared with controls 6 (4) (p < 0.0001). Moreover, the LAAT could effectively discriminate between various grades of disease activity, the values in patients with active disease being 13 (6)% in mild, 17 (10)% in moderate, and 26 (10)% in severe disease (p < 0.0001). Other acute phase reactants including the erythrocyte sedimentation rate, the white blood cell count, the platelet count, neutrophil count, as well as, the C reactive protein concentration did not differentiate as well between the various groups. Using logistic regression analysis to differentiate between inflammatory bowel disease patients in remission or relapse, the LAAT was the single best indicator. The addition of any other test did not contribute to the discrimination. Among the different laboratory variables tested only the LAAT significantly discriminated between the five different subgroups of controls, remission and mild, moderate or severe disease activity.

Adolescent↗

PubMed1995

Post-transfusion etiology and non-cirrhotic histology improve the remission rate of chronic hepatitis C during interferon treatment.

During a 29 month period, 46 patients with chronic hepatitis C virus (HCV) received recombinant human interferon alpha-2a for 6 months and were followed for another 6 months. The dose of interferon was three million units thrice weekly and was increased to six million units if amino transferase levels failed to return to normal after 2 months of therapy. At the end of the treatment 19 patients had a complete response, 6 had a near complete response, 2 patients had breakthrough during treatment, and the remaining 19 did not respond at all. Six months after treatment only 10 of the 19 responders remained in remission. Post-transfusion disease was associated with a significantly higher remission rate than sporadic disease (9/22 vs. 1/24, P < 0.001), as was also found in non-cirrhotic compared to cirrhotic patients (9/27 vs. 1/19, P < 0.001). Age, sex, duration of disease, serum aminotransferase, albumin, bilirubin, alkaline phosphatase, or Child's classification did not correlate with treatment response. Severe side effects necessitating cessation of treatment occurred in six patients, four of whom had major autoimmune phenomena. We conclude that careful selection of HCV patients with favorable response characteristics (post-transfusion etiology and non-cirrhotic liver) and without autoimmune manifestations can improve the remission rate and decrease the complication rate during interferon treatment.

Adult↗