Biomedical subjects

S Watemberg

Publications and source records attributed to S Watemberg.

11 recordsLinked to original sources

PubMed1997

Of balloon axilloscopy and avoidance of iatrogenic injury to the long thoracic nerve.

BACKGROUND: Laparoscopic removal of axillary lymph nodes is possible and affords an excellent view of all structures, allowing preservation of vessels and nerves. The technique uses pediatric trocars and a lifting device to maintain the newly created axillary space. OBJECTIVE: To prove that a newly developed technique of balloon axilloscopy can be performed using only one 10-mm and two 5-mm standard trocars and constant carbon dioxide flow to preserve the axillary space and that preservation of all nerves and vessels is possible with this approach. DESIGN: Prospective study on 4 fresh-frozen human cadavers and 7 live porcine models. SETTING: A hospital department of minimal surgery access and a university department of anatomy. RESULTS: The balloon dissection consistently revealed and preserved the nerves and vessels, and exposure and dissection of the first rib could similarly be accomplished. An alternative route to the apex of the axilla has been developed--between the pectoralis minor and pectoralis major muscles--after their careful separation. The axillary content of surgical interest (lymph nodes) is easily separated from the other anatomical elements and is simply dissected under complete visualization and preservation of all vital axillary structures. CONCLUSIONS: Balloon axilloscopy was easy to perform, provided the surgeon with constant visualization of vital anatomical structures, and allowed easy separation and dissection of the axillary lymph nodes and the first rib. As a technical aid prior to a conventional axillary dissection, or as part of a pure endoscopic procedure in the axilla, balloon axilloscopy is 100% reliable in identifying the long thoracic nerve and moving it out of the way, separating the lymph nodes from it and from the intercostobrachial nerve and axillary vein and artery, rendering the whole dissection process safer for both the surgeon and the patient.

Animals↗

PubMed1997

The secrets of the unknown trauma patient. The hazards of undiagnosed subclavian steal syndrome in the chest trauma patient: a case report.

Chest trauma can be complicated, among others, with cardiac tamponade. This life-threatening condition should be treated promptly and adequately to assure a positive outcome. During the rapid events that take place in the emergency room with the arrival of a polytrauma patient, anamnestic data are not always available, especially if dealing with a non-cooperative, unaccompained traumatized patient. The following case report describes our experience with a chest trauma patient after a vehicle accident, who was admitted to our ward exhibiting a constellation of signs compatible with a cardiac tamponade. The only demonstrable objective signs included distended mediastinum and heart shadow on the chest X ray and muffled heart sounds. However, despite the impressive clinical picture, the patient continued to exhibit constant, though low blood pressure measurements and after a short period of observation, given the homodynamic stability, it was decided against pericardiocenthesis. The "secret" of our patient was finally discovered at angiography, when a left subclavian steal was diagnosed. The literature in this matter is discussed, stressing the importance of anamnestic data in the trauma patient. Most importantly, we address the significance of relying on hard clinical data (homodynamic stability) rather than on isolated signs (widened mediastinum/heart shadow) to reach as accurate a diagnosis as possible before pursuing invasive, usually not-innocuous procedures (pericardiocenthesis).

Accidents, Traffic↗

PubMed1996

Successful treatment of anal tumors with CO2 laser in elderly, high-risk patients.

The central issue in elderly surgery remains the operative risk, which is usually a direct factor of age, ASA classification, and other pathologies, especially cardiovascular diseases. It is the surgeon's role to define properly the risks involved with a patient and to anticipate the involved operative mortality. Based on this, we performed CO2 laser fulguration of anal canal tumors in 10 patients suffering from either squamous cell or adenocarcinoma localized up to 4 cm from the anus. The rationale was to avoid prohibitive operative and anesthetic risk, achieve local control of disease and improve quality of life by avoiding surgical convalescence and an otherwise certain colostomy. All patients underwent fulguration (25-30 W) every 3-4 months. Complications included minor pain and bleeding. Three patients required operation (Hartman's pouch) within 2 1/2 years due to continuous tumor bleeding and stricture of the anal canal. The remaining 7 patients were treated regularly and satisfactorily by fulguration and the mean survival in this group was 8 years (in all cases the causes of death were unrelated to the procedure or the tumor). We conclude that CO2 laser fulguration of anal canal tumors in elderly, high-risk patients represents an invaluable option of treatment, while avoiding major operative risk, controlling the local spread of disease, maintaining physiological bowel function, and avoiding colostomy. Most importantly, the main dividends of the study are patient satisfaction and maintenance of good quality of life.

Adenocarcinoma↗

PubMed1996

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.

Esophagogastric Junction↗

PubMed1995

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.

Autopsy↗

PubMed1995

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.

Autopsy↗

PubMed1995

The use of CO2 laser for inguinal hernia repair in elderly, pacemaker wearers.

Interference of electrical current with pacemaker activity is well known and has long been described. Almost every surgical procedure is now performed with the electrical knife, or electrocautery. In patients wearing a pacemaker this poses a problem, because of the danger of electronic interference within the pacemaker with consequent firing-frequency changes and the higher risk of intra- and postoperative bleeding and oozing when using a scalpel instead of cautery. We have performed 25 hernioplasties in elderly patients with permanent pacemakers using the CO2 laser technique. All operations were technically successful, and the immediate and long term (1 year) follow-up proved uneventful. Additionally normal pacemaker function was maintained during surgery and through the follow-up period. CO2 laser surgery is advantageous over electrocautery in patients with pacemakers because it does not interfere with pacemaker activity. Moreover, the laser produces normal hemostasis and does not stimulate muscle and nerve activity during surgery.

Aged↗

PubMed1995

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.

Autopsy↗

PubMed1995

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.

Cholecystectomy, Laparoscopic↗

PubMedDate not supplied

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.

Aged↗

PubMedDate not supplied

Incidental cholecystectomy in the over-70 age group. A 19-year retrospective, comparative study.

OBJECTIVES: To analyse the outcome of incidental cholecystectomy in the over 70 age-group during surgery for gastrointestinal malignancies. DESIGN: Nineteen-year retrospective, comparative study. SETTING: Department of Surgery B, Belinson Campus, Rabin Medical Center. SUBJECTS: The hospitalization records of 4,072 patients who underwent cholecystectomy between 1975 and 1994 were reviewed. The incidental cholecystectomy cases for this period were identified and those performed during surgery for gastrointestinal malignancy were analysed separately. A sex- and age-matched control group was identified for comparison. MAIN OUTCOME MEASURES: Postoperative complications, overall morbidity and mortality, postoperative hospitalization days. Statistical differences in gallbladder-related complications and mortality among groups. RESULTS: Mortality and overall morbidity were significantly increased in the no-cholecystectomy group. Hospitalization days were increased significantly in the group not under-going cholecystectomy and although it didn't reach statistical significance, there was a clear trend for increased number of pulmonary complication in this same group. Sepsis and multiorgan failure, as an expression of acutely, postoperative symptomatic gallbladder were the major cause of death in the no-incidental-cholecystectomy group. CONCLUSIONS: Incidental cholecystectomy is safe and should be considered in every case of abdominal surgery, regardless of the age of the patient. In the over 70 age group, complication and mortality rates increase significantly and dreadfully when the gallbladder is left in situ after surgery for gastrointestinal tumors. Incidental cholecystectomy is not warranted in patients undergoing palliative procedures or in whom life expectancy is less than 6 months.

Age Factors↗