Biomedical subjects
R Avrahami
Publications and source records attributed to R Avrahami.
Zenker's diverticulum: reappraisal.
For more than 2 centuries, the nature and pathophysiology of pharyngoesophageal (Zenker's) diverticulum has been a matter of argument. The intrinsic or extrinsic forces and structures that might play a role in the development of this disorder have been repeatedly scrutinized, and still today the different theories of muscular incoordination and/or spasm, cricopharyngeal achalasia, gastroesophageal reflux, or neuromuscular abnormalities try to find their way as the final word regarding etiology remains to be told. Options for treatment follow a similar pattern although myotomy and diverticulopexy seem to have yielded the best results. In this review, historical and current data gathered from the world literature are compiled in an attempt to give a clear overview of the pathophysiology surrounding the genesis of Zenker's diverticulum and the clinical manifestations, diagnosis, and different alternatives for definite treatment of this disorder.
Laparoscopic vs conventional autopsy. A promising perspective.
OBJECTIVE: To analyze the sensitivity and specificity of laparoscopic autopsy when compared with the ulterior performance of conventional postmortem examination. DESIGN: Consecutive sampling, case-series study. SETTING: A general community referral medical center and the local institute of forensic medicine. PARTICIPANTS: A consecutive sample of 25 fresh cadavers (< 24 hours old) of victims of vehicle accidents, gunshot wounds, and in-hospital deaths. INTERVENTIONS: After insufflation with carbon dioxide, laparoscopy of the abdominal cavity and inspection of the retroperitoneal area was accomplished. Following, a conventional postmortem examination was performed and the findings of both procedures were recorded, compared, and analyzed. MAIN OUTCOME MEASURES: Prior to the beginning of the study, it was hypothesized that laparoscopic autopsy would reach an overall sensitivity and specificity of at least 85% and enable accurate inspection of the abdominal cavity and retroperitoneum in the search for the trauma-related cause of death in trauma victims or the cause of death for in-hospital patients. RESULTS: There was a 100% correlation of both procedures in all accidental cases. The sensitivity of laparoscopic autopsy was 93% for intra-abdominal lesions, with an overall sensitivity of 91%. For the retroperitoneal area, the sensitivity was 58%. The sensitivity for the retroperitoneum dropped, owing to an intrarenal tumor and an extraperitoneal rectal tear in the small sample of inhospital deaths. The specificity of laparoscopic autopsy reached 94%. CONCLUSIONS: Laparoscopic autopsy is accurate and easy to perform. It is highly sensitive for intra-abdominal abnormalities, especially in trauma victims. Laparoscopic autopsy is minimally invasive and not disfiguring, rendering it easier to accept among mourning families. It should be strongly considered when consent for a conventional autopsy is lacking.
Thoracoscopy vs conventional autopsy of the thorax. A promising perspective.
OBJECTIVE: To analyze the sensitivity and specificity of thoracoscopic autopsy compared with that of conventional postmortem examination. DESIGN: Consecutive sampling, case-series study. SETTING: A general community referral center and the local Institute of Forensic Medicine. PARTICIPANTS: A consecutive sample of 20 fresh cadavers (less than 24 hours old), victims of motor vehicle crashes, gunshot wounds, in-hospital deaths. INTERVENTIONS: Introduction of the thoracoscope through the fourth or fifth intercostal space, anterior or midaxillary line. The pleural cavity and mediastinum were examined. Formal postmortem examination was then performed, and the findings of both procedures were recorded, compared, and analyzed. MAIN OUTCOME MEASURES: Prior to the beginning of the study, it was hypothesized that thoracoscopic autopsy would reach an overall sensitivity and specificity of at least 85% and enable accurate inspection of the thoracic cavity and mediastinum in search of trauma-related abnormalities in trauma victims or cause of death in in-hospital patients. RESULTS: There was an 85% correlation of both procedures in all cases. The sensitivity of thoracoscopic autopsy was 87% and overall specificity reached 72%. CONCLUSIONS: Thoracoscopic autopsy is accurate and easy to perform. It is highly sensitive, especially in deaths due to trauma and following thoracic surgery. Thoracoscopic autopsy is an important tool that allows the diagnosis of major chest abnormalities as well as ruling out postoperative catastrophe, information that is invaluable for the surgeon, as well as all the medical staff and families. Thoracoscopic postmortem examination should be offered to mourning families as a cosmetic and reliable option when informed consent for conventional autopsy is lacking.
Endoscopic autopsy.
In cases in which the family of the deceased objects to the performance of a conventional autopsy for religious or other reasons, or where there are no forensic pathology facilities in the vicinity of the hospital, postmortem endoscopic examination may be an advantageous and cost-effective substitute for conventional necropsy, especially when the alternative is no postmortem examination at all. To test the reliability of postmortem endoscopy, conventional and endoscopic autopsies were performed on 20 cadavers at the L. Greenberg Institute of Forensic Medicine in Israel. Comparison of the findings of the two procedures showed a very high correlation (100%) for intraperitoneal and thoracic hemorrhages and hepatic, splenic, and diaphragmatic injuries; it showed a slightly lower correlation (60-80%) for mesenteric and retroperitoneal hematomas injuries to the great vessels, blood aspiration, and lung injury. Endoscopy failed to reveal the correct site of injury in the retroperitoneum and posterior aspect of the mediastinum. Collection of body fluids and tissue samples was possible by means of laparoscopy. The technique proved to be relatively accurate, more rapid than conventional autopsy, and left the body virtually intact.
Agenesis of the gallbladder found at laparoscopy for cholecystectomy: an unpleasant surprise.
Gallbladder agenesis is a rare condition that results from the failure of the cystic bud to develop in the 4th wk of intrauterine life. Agenesis is usually discovered at laparotomy for cholecystectomy since ultrasound examination of a patient with suggestive symptoms not visualizing the gallbladder is compatible with chronic cholecystitis (shrunken gallbladder). The surgeon must prove agenesis by thoroughly examining the most common sites for ectopic gallbladders and by performing intraoperative cholangiograms. For unexplained reasons, most of the patients become asymptomatic after the operation. We present a new case of adult agenesis of the gallbladder in a patient who was taken to laparoscopic cholecystectomy for presumptive cholelithiasis.
Survival and long-term outcome of infants delivered at 24 to 28 weeks' gestation, by method of delivery and fetal presentation.
Significant advances in perinatal intensive care and the increased chances of neonatal survival that have evolved in the last decade have posed moral and medicolegal questions for obstetricians that are as yet unanswered. Aggressive delivery management and major interventions for infants who were not long ago considered to be nonviable have become increasingly common. On the other hand, reports of high incidence of handicaps in the survivors cause great concern and add to the dilemma facing obstetricians. In this study, survival and long-term morbidity in 169 infants delivered at 24 to 28 weeks' gestation have been analyzed according to method of delivery and fetal presentation. At 24 to 25 weeks, survival was extremely low (10.5%) while major handicap rate was very high (42.9%). Infants born at 26 to 28 weeks' gestation had a considerably higher survival potential (42% to 74%), with an incidence of major handicap of less than 10%. At 26 to 28 weeks, abdominal delivery did not alter survival prospects of vertex-presenting infants; however, it improved survival of breech-presenting infants (70.0% compared with 22.2%) and showed a trend toward a lower handicap rate in the survivors.
The role of percutaneous transhepatic cholecystostomy in the management of acute cholecystitis in high-risk patients.
A method recently developed that may be an appropriate solution for high-risk patients with acute cholecystitis is percutaneous sonography-guided cholecystostomy. We report our experience in 10 high-risk elderly patients with clinical and sonographic diagnosis of acute cholecystitis. Immediate regression and resolution of septic symptoms was achieved in all cases. One patient was operated on as soon as his clinical condition stabilized, with uneventful postoperative recovery. The other nine were considered inoperable; of these, two were readmitted within a few months with recurrence of symptoms who underwent surgery, with a long and complicated postoperative course. The only complication we observed was temporary septicemia in one patient immediately after completion of the procedure. In view of these findings, we consider percutaneous transhepatic cholecystostomy an effective and safe method of treatment for acute cholecystitis in critically ill patients. However, this procedure should be regarded as a preliminary measure only, to render the patient more suitable for a formal cholecystectomy. We report our results and discuss technical and principal matters concerning percutaneous transhepatic cholecystostomy in the light of the current literature.