Zvi Halpern

Pseudoaneurysm of the dorsalis pedis artery

Two cases of post-traumatic pseudoaneurysm of the dorsalis pedis artery are presented. Both were managed by resection and vascular reconstruction with a successful result. It is suggested that this, rather than resection and ligation, is the preferred treatment in these cases.

Is male gender a risk factor for conversion of laparoscopic into open cholecystectomy

AbstractBackground: Based on a clinical observation that the conversion rate of laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) is higher in males, we decided to review our records and to verify whether a significant difference in conversion rates exists between sexes. Methods: A retrospective study on conversion rates of elective laparoscopic cholecystectomy (LC) into open cholecystectomy (LC) in relation to gender was carried out in 329 patients: 267 females and 62 males. Results: Our data revealed that the probability of conversion is fivefold greater in males than females, 21% vs 4.5%, respectively (p=0.0001). We attribute this striking difference to significantly more adhesions (p=0.0002) and anatomical difficulties (p=0.003) in males during LC, leading to conversion. Conclusions: We conclude that conversion of LC to OC is more prevalent among males and is probably attributable to a greater incidence of anatomical difficulties.

Pulse oximetry in the evaluation of the painful hand after arteriovenous fistula creation

Five patients with a side-to-side arteriovenous fistula complaining of pain, numbness, and cold sensation were evaluated by pulse oximetry. Low SaO2 was noticed in all five. Closure of a major proximal venous collateral vessel eliminated the steal and resulted in SaO2 correction and was followed by clinical amelioration. Pulse oximetry proved to be a helpful adjunct in the evaluation of the painful hand after creation of an arteriovenous fistula. By applying the pulse oximeter to the patients affected limb, we were able to determine whether the pain was a result of ischemia and if the correction of the steal improved oxygenation.

The accuracy of sentinel node mapping according to T stage in patients with gastric cancer

BackgroundSentinel lymph node (SLN) mapping has been recently introduced to the field of gastric cancer. To the best of our knowledge, no study has dealt with the accuracy of SLN mapping according to the T stage of the primary tumor. The aim of the present study was to evaluate SLN status according to the T stage of the primary tumors.MethodsEighty patients with gastric cancer underwent SLN mapping with patent blue dye during gastric resection.ResultsForty-seven patients underwent distal subtotal gastrectomy; 17 patients, proximal gastrectomy; 14, total gastrectomy; and 2, gastric stump resection. SLNs were stained in 61/80 patients (76.3%). The number of stained SLNs varied from 1 to 16 (mean, 3.3). Patients undergoing proximal gastrectomy had a mean of 3 stained SLNs, whereas patients undergoing distal subtotal gastrectomy had a mean of 2.8 stained SLNs. In 55/61 patients (90.2%) with stained SLNs a positive correlation was found between the presence of metastases and stained or non-stained SLNs. Ten out of 11 patients (90.9%) with T1 tumors (mean, 3.27 SLNs per patient) and 15/17 patients with T2 tumors (88.2%; mean, 3 SLNs per patient) had stained SLNs as compared to only 33/48 (68.8%) of patients with T3 tumors (mean, 3.3 SLNs per patient). The positive predictive value of the SLN mapping was 100%, the negative predictive value was 76.9%, and sensitivity was 85.4%.ConclusionWhile in T1 and T2 tumors sentinel node mapping may be of assistance in the decision-making process regarding the extent of lymphadenectomy (sensitivity, 100%; negative predictive value, 90%-100%), SLN mapping in patients with T3 tumors will be misleading in a third of the patients and should not be attempted.

The fate of long-standing intraperitoneal gallstone in the rat

Gallstones are occasionally spilled into the peritoneal cavity during open and laparoscopic cholecystectomy. Using the rat model, we investigated the long term effect of such retained intraperitoneal gallstones. During a follow-up period of one year, no systemic deleterious outcome could be attributed to the presence of the implanted gallstones except for mild local effects. Based on the rat model we conclude that reasonable effort should be made in order to retrieve an escaped gallstone, but there is no justification whatsoever for a conversion of the laparoscopic procedure to an open laparotomy only for the purpose of retrieving a lost stone.

The laparoscopic second look for ischemic bowel disease

AbstractBackground: Survival after acute vascular ischemia depends on a second look laparotomy to detect extending bowel compromise and to verify the integrity of the anastomosis. In a series of five consecutive patients with acute ischemic bowel desease, we used laparoscopic technique to determine if a formal laparotomy could be avoided. Methods: following the resection of ischemic bowel in five consecutive patients, two laparoscopic trocars were inserted in the lower abdominal quadrants and covered by sterile gloves. Forty-eight to 72 h following the primary operation, the abdomen was inflated via a trocar and secondary assessement done by laparoscopy. Results: In all patients, the integrity of the anastomosis and viability of the remaining bowel was accurately assessed by laparoscopy. Conclusions: Using mininally invasive techniques, a second look laparotomy was avoided in 5 patients with ischemic bowel disease.

Pulse oxymetry evaluation of oxygen saturation in the upper extremity with an arteriovenous fistula before and during hemodialysis

We noticed that some patients with arteriovenous (AV) fistula on chronic hemodialysis experience pain in the limb with the fistula a short time after being connected to the dialysis machine. We postulated that the pain is caused by relative ischemia and therefore performed this study to determine whether oxygen saturation (SaO2) of the extremities with AV fistula decreases during hemodialysis. Seventy-two patients with a side-to-side primary AV fistula were evaluated by pulse oxymetry. SaO2 was measured before hemodialysis and 20 minutes after initiation of dialysis. The contralateral arm served as a control. In 48 patients, SaO2 difference between the arms of each patient before hemodialysis was less than 4%. SaO2 values of this group of patients did not change significantly 20 minutes after initiation of dialysis. In 24 patients, SaO2 differences between the hands of each patient before hemodialysis were 4% or more. In this group of patients, SaO2 values of the hands with the AV fistula decreased significantly 20 minutes after hemodialysis from a mean of 90.85 +/- 2.84% to 81.60 +/- 3.94 (P < 0.001). SaO2 remained unchanged in the contralateral arm. Nine patients in this group complained of pain and change in sensation in the arm with the fistula during hemodialysis. One patient complained of severe pain in the arm with the fistula before hemodialysis, and SaO2 was unmeasurable. We conclude that, in some patients, SaO2 of the arm with the AV fistula decreases only during hemodialysis. This phenomenon may be symptomatic. A predialysis SaO2 difference of 4% or more between the arms predicts decreased SaO2 of the arm with the AV fistula during hemodialysis.

Gastric Emptying Half-time Following Silastic Ring Vertical Gastroplasty: A Scintigraphic Study (Preliminary Results)

Background: The mechanism for weight loss following gastroplasty surgery is unknown. A few studies have checked gastric emptying patterns following gastroplasty, but none have analysed their pattern over time. Methods: Gastric emptying half-time of Tc-99 phytate-labeled semi-solid meal was studied in 23 obese non-diabetic and one diabetic patient (BMI 34.6-55.7). Gastric emptying was measured by gamma scintigraphy before Silastic Ring Vertical Gastroplasty (SRVG) and 1, 3 and 6 months following surgery. Results: Gastric emptying half-times were maximal in all areas of the stomach 1 month after operation, declined to base-line 3 months following the procedure, and showed statistically significant delay in the upper area of the stomach 6 months after the operation. No correlation was found between the delay in food passage following surgery and loss of weight. Conclusions: Prolongation of gastric emptying half-time following surgery may be a result of two separate mechanisms: asymptomatic or early inflammatory processes in the ring area and pouch distention as a result of partial denervation.

Nerve Conduction Abnormalities in the Arms of Patients with Arteriovenous Fistula

Fifteen patients with unilateral functioning arteriovenous fistula were assessed clinically and electromyographically to identify local neurologic changes. Ten of the patients were symptomatic (motor and/or sensory) and 5 were asymptomatic. Clinically, 11 patients had signs of a mild polyneuropathy, 2 patients of ulnar neuropathy, and 1 patient had signs of median neuropathy. A decrease of the above-elbow ulnar conduction velocity was noted in the study group on the side of the functional fistula, and in the symptomatic patients only on the side of the nonfunctional/nonexisting fistula. We suggest that ulnar nerve vulnerability should be taken into consideration during construction of the fistula, as well as during dialysis.

Intra – and Retroperitoneal Bleeding Associated with Anticoagulant Therapy

Intra- and retroperitoneal bleeding may be associated with anticoagulant therapy and presents the gastroenterological surgeon with a diagnostic and therapeutic dilemma. Although these rare types of bleeding may be spontaneous, minimal trauma cannot be ruled out. In the case of retroperitoneal hemorrhage, conservative management may suffice, but in the case of intraperitoneal bleeding, urgent laparotomy may be required. It is not possible to elicit causal factors, and elderly patients on anticoagulant therapy should be carefully monitored on the appearance of any abdominal complaints.