Presentation of Ascariasis as a Cause of Acute Intestinal Obstruction

Ascariasis infection is prevalent in tropical and subtropical locations worldwide. The occurrence of ascariasis is associated with poverty, inadequate hygiene, and inadequate fecal sanitation. This helminth often resides innocuously in the small intestine, but it may sometimes lead to intestinal blockage or perforation, resulting in peritonitis, a condition frequently seen in children. Ascariasis may also migrate via the ampulla of Vater, leading to the development of cholangitis, pancreatitis, cholecystitis, and, in rare cases, hepatic abscesses. Occasionally, an Ascaris-induced hepatic abscess may manifest as an acute abdomen, resembling an acute pyogenic abscess. We report the case of a four-and-a-half-year-old male child from Khedi Sikarpur, Haridwar, India, who was admitted to the pediatric department. The patient presented with acute colicky abdominal pain localized to the abdomen, accompanied by vomiting and constipation for three days. Additionally, the patient experienced abdominal distension for one day. There was no history of bleeding manifestations or decreased urine output.

Distribution of Perigastric Station 4d Lymph Nodes in Vascularized Gastroepiploic Lymph Node Transfer: An Anatomic Study and Case Series

BACKGROUND

Vascularized gastroepiploic lymph node transfer (VGLNT) is a well-accepted surgical treatment for restoring physiological function in chronic lymphedema. However, the inclusion of substantial lymph nodes (LNs) in the flap remains uncertain. This study aimed to identify the anatomical basis for reliable flap harvest for VGLNT.

PATIENTS AND METHODS

The anatomy of perigastric station 4d LNs was studied in healthy cadavers (n = 15) and patients with early gastric cancer (EGC) (n = 27). The omentum was divided into three segments: proximal, middle, and distal from the origin of the right gastroepiploic vessels. The flap dimension, number, location, size of LNs, and caliber of the vessels were reviewed. Eight patients underwent VGLNT for upper/lower limb lymphedema.

RESULTS

The mean numbers of LNs in the proximal, middle, and distal segment were 2.5, 1.4, 0.5 in the cadavers, and 4.9, 2.7, 0.7 in the gastrectomy specimens, respectively. The proximal third included a significantly greater number of LNs than the distal third in the cadaveric (p = 0.024) and ECG (p = 0.016) specimens. A total of 95% of the LNs were located within proximal two-thirds of the flap from the vessel origin both in the cadavers (21.0 × 5.0 cm) and in the gastrectomy specimens (20 × 3.5 cm). In VGLNT, the transferred flap was 25.5 ± 6.9 × 4.1 + 0.7 cm in dimension, containing a mean number of 6.5 ± 1.9 LNs. At postoperative 6 months, the volumetric difference was significantly reduced by 22.8 ± 9.2% (p < 0.001).

CONCLUSIONS

This study provides a distinct distribution pattern of station 4d LNs. Inclusion of the proximal two-thirds of the flap, which carries majority of the LNs, is recommended for VGLNT.

Intraoperative Indocyanine Green Angiography Facilitates Flap Fenestration and Facial Organ Fabrication in Total Facial Restoration

BACKGROUND

Because of a lack of effective measures to visualize flap vasculature and perfusion, flap fenestration and facial organ fabrication cannot be performed effectively, preventing the transition from two-dimensional coverage to restoration of the three-dimensional (3D) structure of facial organs. This study aimed to evaluate the efficacy of indocyanine green angiography (ICGA) in guiding flap fenestration and facial organ fabrication in total facial restoration.

METHODS

Ten patients with total facial scarring after burn injury were enrolled in the study. They were treated with preexpanded, prefabricated monoblock flaps for total face restoration. The openings of nostrils and oral and palpebral orifices, together with organ fabrication, were conducted under the guidance of intraoperative ICGA by hemodynamic evaluation of flap perfusion. Postoperative follow-up measures include vascular crisis, infection, flap necrosis, and aesthetic and functional recovery.

RESULTS

The opening of facial organ orifices was performed at the stage of flap transfer in nine patients. To avoid damaging the major nourishing vessels, the left palpebral orifice was opened 8 days after the flap transfer in one patient, as observed by ICGA. Based on ICGA evaluation, the decision to perform additional vascular anastomosis before flap fenestration was made in six patients. Hemodynamic analysis of flap perfusion after fenestration revealed no significant change. Follow-up showed satisfactory aesthetic recovery and well-restored 3D structures of facial organs.

CONCLUSION

This pilot study demonstrates how intraoperative ICGA can enhance the safety of flap fenestration, thereby transforming full facial restoration from the two-dimensional to the 3D realm by facilitating facial organ fabrication.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Venovenous bypass in adult liver transplant recipients: A single-center observational case series

BACKGROUND

Very little information is currently available on the use and outcomes of venovenous bypass (VVB) in liver transplantation (LT) in adults in Australia. In this study, we explored the indications, intraoperative course, and postoperative outcomes of patients who underwent VVB in a high-volume LT unit.

METHODS

The study was a single-center, retrospective observational case series of adult patients who underwent VVB during LT at Austin Health in Melbourne, Australia between March 2008 and March 2022. Information on baseline preoperative status and intraoperative variables, including specific VVB characteristics as well as postoperative and VVB-related complications was collected. The lengths of intensive care unit and hospital stays as well as intraoperative and in-hospital mortality were recorded.

RESULTS

Of the 900 LTs performed at this center during the aforementioned 14-year period, 27 (3%) included a VVB procedure. VVB was performed electively in 16 of these 27 patients (59.3%) and as a rescue technique to control massive bleeding in the other 11 (40.1%). The median (interquartile range [IQR]) age of those who underwent VVB procedures was 48 (39-55) years; the median age was 56 (47-62) years in the non-VVB group (p<0.0001). The median model for end-stage liver disease (MELD) scores were similar between the two patient groups. Complete blood data was available for 622 non-VVB patients. Twenty-six VVB (96.3%) and 603 non-VVB (96.9%) patients required intraoperative blood transfusions. The median (IQR) number of units of packed red blood cells transfused was 7 (4.8-12.5) units in the VVB group compared to 3.0 units (1.0-6.0) in the non-VVB group (p<0.0001). Inpatient mortality was 18.5% and 1.1% for the VVB and non-VVB groups, respectively (p<0.0001). There were no significant differences in length of hospital stay or incidence of acute kidney injury, primary graft dysfunction, or long-term graft failure between the two groups. Patients in the VVB group experienced a higher rate of postoperative non-anastomotic biliary stricture compared to patients in the non-VVB group (33% and 7.9%, respectively; p = 0.0003).

CONCLUSIONS

VVB continues to play a vital role in LT. This case series highlights the heightened risk of major complications linked to VVB. However, the global transition to selective use of VVB underscores the urgent need for collaborative multi-center studies designed to address outstanding questions and parameters related to the safe implementation of this procedure.

Long-term Outcome Comparison of 2 Techniques for Embolization of Splenic Artery Aneurysms

PURPOSE

The aim of the study is to analyze our single-center experience in endovascular treatment of splenic artery aneurysms (SAAs) with transcatheter coil embolization, comparing long-term outcomes of packing and sandwich techniques.

MATERIALS AND METHODS

Between January 2010 and December 2021, 28 patients with certain diagnosis of non-ruptured asymptomatic SAA were treated with 2 different embolization techniques (packing, n=10, and sandwich, n=18). Early outcomes assessed were technical success, overall mortality, mean hospital stay, post-embolization syndrome rate, and freedom from splenectomy rate. Estimated 5-year outcomes in terms of freedom from sac reperfusion, and freedom from reintervention were evaluated and compared between the 2 different embolization techniques.

RESULTS

The mean SAA diameter was 2.8±0.8 cm. Overall technical success rate was 100%. Intraoperative and 30-day mortality rates were 0 in both groups. One patient in the sandwich group required a postoperative splenectomy. The mean follow-up period was 58.3±44.5 months. Estimated overall 5-year survival was 86.7%. Five-year freedom from sac reperfusion was 100% in the sandwich group, and 85.7% in the packing group, with no difference between the 2 groups (p=0.131), whereas freedom from reintervention was 100% in the sandwich group, and 75% in the packing group with a statistically significant difference (p=0.049; log-rank=3.750).

CONCLUSIONS

Embolization of SAAs seemed to be safe and effective with 100% of technical success rate and good perioperative results. Both sandwich and packing techniques yielded promising results also in the long-term period.

CLINICAL IMPACT

Transcatheter coil embolization of splenic artery aneurysms seems to be a safe and effective procedure with a 100% technical success and satisfactory perioperative outcomes. Sandwich and packing techniques offer good results in the long-term period. Freedom from reintervention seems to be optimal and comparable between the 2 techniques.

Biliary Ascariasis in a Pediatric Patient in Lithuania: Case Report and Literature Review

Hepatobiliary ascariasis is caused by the entry of the nematode A. lumbricoides from the duodenum into the biliary duct. We report a case of an Ascaris-induced extrahepatic biliary tract obstruction in a pediatric patient admitted to the hospital due to a wide spectrum of symptoms of biliary disease, which included abdominal pain in the upper abdominal quadrants, vomiting, and jaundice. Imaging tests-including ultrasound, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP)-were performed to confirm the diagnosis of biliary ascariasis. The tests did, in fact, demonstrate signs of this disease. Nevertheless, during the ERCP, only the remains of Ascaris parasites in the form of tissue fragments were extracted. We also aim to discuss the prevalence of ascariasis in children, the causes of migration of Ascaris parasites into the bile ducts, together with its clinical manifestations, as well as the diagnostic and treatment methods of this disease.

Intra-operative extracorporeal irradiation of tumour-invaded craniotomy bone flap in meningioma: a case series

BACKGROUND

Extracorporeal irradiation of tumorous calvaria (EITC) can be performed to restore function and form of the skull after resection of bone-invasive meningioma. We sought to examine the rate of tumour recurrence and other selected outcomes in patients undergoing meningioma resection and EITC.

METHODS

Retrospective single-centre study of adult patients undergoing meningioma resection and EITC between January 2015 and November 2022 at a tertiary neurosurgical centre. Patient demographics, surgery data, tumour data, use of adjuvant therapy, surgical complications, and tumour recurrences were collected.

RESULTS

Eighteen patients with 11 (61%) CNS WHO grade 1, 6 (33%) grade 2, and 1 (6%) grade 3 meningiomas were included. Median follow-up was 42 months (range 3-88). Five (28%) patients had a recurrence, but none were associated with the bone flap. Two (11%) wound infections requiring explant surgery occurred. Six (33%) patients required a further operation. Two operations were for recurrences, one was for infection, one was a washout and wound exploration but no evidence of infection was found, one patient requested the removal of a small titanium implant, and one patient required a ventriculoperitoneal shunt for a persistent CSF collection. There were no cases of bone flap resorption and cosmetic outcome was not routinely recorded.

CONCLUSION

EITC is feasible and fast to perform with good outcomes and cost-effectiveness compared to other reconstructive methods. We observed similar recurrence rates and lower infection rates requiring explant compared to the largest series of cranioplasty in meningioma. Cosmetic outcome is universally under-reported and should be reported in future studies.

A Novel and Reproducible Classification of Cervical Dumbbell Tumors to Inform Surgical Approach and Reconstruction Techniques

STUDY DESIGN

A retrospective case series.

OBJECTIVE

This study developed a novel classification system based on imaging and anatomy to select optimal surgical approaches and reconstruction strategies to achieve total resection of cervical dumbbell tumors and restore spinal stability.

SUMMARY OF BACKGROUND DATA

Total resection is necessary to decrease the recurrence rate of cervical dumbbell tumors. Previous cervical dumbbell tumor classifications are insufficient for determining surgical strategies; therefore, a practical classification is needed.

MATERIALS AND METHODS

This study included 295 consecutive patients with cervical dumbbell tumors who underwent total surgical resection. A novel classification of cervical dumbbell tumors was developed based on magnetic resonance imaging and computed tomography. Continuous variables were expressed as mean±SD and were compared using an unpaired two-tailed Student t test. The χ 2 test or the Fisher exact test was used for categorical variables. Kendall's W test assessed three independent raters' inter-rater and intrarater reliabilities on 140 cervical dumbbell tumors.

RESULTS

The inter-rater and intrarater consistency coefficient was 0.969 (χ 2 =404.3, P <0.001) and 0.984 (χ 2 =273.7, P <0.001). All patients with type I and II tumors underwent single-posterior surgeries to achieve total resection. Of the patients in this study, 86.1%, 25.9%, 75.9%, and 76.9% underwent posterior surgeries for types IIIa, IIIb, IVa, and V tumors, respectively. All patients with type IVb tumors underwent a combined anterior and posterior approach. Posterior internal fixation was used for all patients in posterior surgery. Anterior reconstruction was applied for patients with type IVb tumors (20/20, 100%) and some with type V tumors (3/13, 23.1%). The mean follow-up duration was 93.6±2.6 months. A recurrence was observed in 19 (6.4%) patients.

CONCLUSION

The authors describe a novel classification system that is of practical use for planning the complete resection of cervical dumbbell tumors.

Feasibility and complications after transoral endoscopic thyroidectomy via vestibular approach (TOETVA) - a single-center first experience case series

BACKGROUND

This paper reports on the first experience after implementation of a transoral endoscopic thyroidectomy via vestibular approach (TOETVA) as an alternative to (partial) thyroidectomy or isthmusectomy in a single center. Feasibility, implementation and specific complications are addressed.

METHODS

All patients who underwent a TOETVA procedure in our center between November 2019 and March 2023 were included. The surgical technique was performed as described by Anuwong et al. All procedures were performed by two dedicated head- and neck surgeons.

RESULTS

A total of 20 patients were included. All patients underwent TOETVA surgery as planned and no conversions were needed. Observed complications were post-operative wound infections (POWI) (2/20; 10%), clinically significant seroma (1/20, 5%) and unilateral hemiparesis of the larynx (3/20; 15%). Permanent mental nerve damage was seen in 3/20 patients (15%), and 4 other patients (20%) experienced transient neuropraxia.

CONCLUSIONS

TOETVA is a feasible alternative to (partial) thyroidectomy or isthmusectomy in selected patients. Special care should be taken when placing the trocars in the oral vestibulum to prevent mental nerve damage. Experience and training are essential for implementing the TOETVA procedure.

TRIAL REGISTRATION

This study was registered to ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT05396703.

Long-term outcomes after acute primary angle closure: case series from Moorfields Eye Hospital, UK

BACKGROUND

There is limited data regarding the morbidity and progression to primary angle closure glaucoma in those presenting with acute primary angle closure (APAC) in the UK. We aim to report on the vision and intraocular pressure (IOP) outcomes and treatment required after an APAC episode and to identify any risk factors that could predict worse outcomes.

METHODS

A retrospective observational case series review including 117 consecutive patients (121 eyes) attending Moorfields Eye Hospital, at a tertiary referral unit in the UK, with APAC was performed.

RESULTS

Most patients (73%) had visual acuities of ≥6/12, meeting the UK driving standard, at the final follow-up. Only 15% (17 eyes) had severe visual impairment, as defined by the WHO, in the affected eye, of which 6.6% (eight eyes) were due to glaucoma. The delayed presentation was linked to a higher need for further medical treatment (OR=2.83, 95% CI 1.09 to 7.40, p=0.03). Patients who underwent phacoemulsification were at lower risk of having blindness in the affected eye (OR 0.18, 95% CI 0.05 to 0.69, p=0.01), having elevated IOP (OR 0.10, 95% CI 0.01 to 0.75, p=0.02) or requiring further medical treatment (OR 0.34, 95% CI 0.12 to 0.99, p=0.04). Older age (OR 1.26, 95% CI 1.08 to 1.48, p<0.01) was associated with worse visual outcomes.

CONCLUSIONS

APAC causes low long-term visual and treatment morbidity in this largely Caucasian patient group in the UK. Phacoemulsification as a treatment may enhance visual outcomes and reduce the need for further IOP-lowering treatment.

Salvage Aneurysmorrhaphy as an Adaptable and Still Pertinent Technique in the Management of Challenging True Aneurysms of Arteriovenous Fistulas: A Case Series of Different Variations, With Illustrative Surgical Pictures

Introduction

Aneurysmorrhaphy, described as reduction aneurysmoplasty, partial aneurysmectomy, or vessel wall recalibration, can be considered a suitable surgical plan for true aneurysms of arteriovenous fistulas (AVFs), allowing for a dynamic approach to reconstruction of aneurysmal AVFs of different severities, ensuring salvage of the native access.

Report

Six challenging cases of AVF aneurysms are presented, some with extremely dilated and tortuous megafistulas, for which three surgical technique variations were performed. The patients had a mean age of 59.2 years, 50% were female, with brachiocephalic (n = 5, 83.3%) or brachiobasilic (n = 1, 16.7%) AVFs. The fistulas were created an average of 4.67 years previously, and the aneurysms had an average maximum diameter of 37.5 mm (range 25-60 mm). Surgical indications were rupture risk, thrombosis, or outflow stenosis compromising haemodialysis, infections, and concerns for quality of life (affected by post-puncture bleedings, disfiguring aesthetics, pain, and discomfort). The surgical techniques were simple aneurysmorrhaphy (n = 3, 50%), aneurysmorrhaphy with partial excision of aneurysmal segment with end to end anastomosis of venous ends (n = 2, 33.3%), and aneurysmorrhaphy with establishment of new venous outflow (n = 1, 16.7%). All AVFs were patent post-operatively and at follow up (mean 5.6 months, median one month). Haemodialysis was resumed through the AVFs at a mean of 2.17 weeks post-operatively, with placement of an alternative route for haemodialysis in the meantime. No patients experienced post-operative complications.

Discussion

Experience with the more challenging cases shows that aneurysmorrhaphy can still be considered an acceptable, flexible, and pertinent method for salvage of megafistulas, giving the surgeon the much needed versatility to adapt to anatomical and pathological variations, with high patency rates and minimal complications, especially when other treatment options are not possible in complicated cases. AVF salvage through aneurysmorrhaphy allows for a dynamic approach to the reconstruction of severely tortuous, dilated veins, ensuring patency of the native AVF.

Lessons learned from revision procedures: a case series pleading for reinforcement of the anterior hiatus in recurrent hiatal hernia

BACKGROUND

Hiatal Hernia (HH) is a common structural defect of the diaphragm. Laparoscopic repair with suturing of the hiatal pillars followed by fundoplication has become standard practice. In an attempt to lower HH recurrence rates, mesh reinforcement, commonly located at the posterior site of the esophageal hiatus, has been used. However, effectiveness of posterior mesh augmentation is still up to debate. There is a lack of understanding of the mechanism of recurrence requiring further investigation. We investigated the anatomic location of HH recurrences in an attempt to assess why HH recurrence rates remain high despite various attempts with mesh reinforcement.

METHODS

A retrospective case series of prospectively collected data from patients with hiatal hernia repair between 2012 and 2020 was performed. In total, 54 patients with a recurrent hiatal hernia operation were included in the study. Video clips from the revision procedure were analyzed by a surgical registrar and senior surgeon to assess the anatomic location of recurrent HH. For the assessment, the esophageal hiatus was divided into four equal quadrants. Additionally, patient demographics, hiatal hernia characteristics, and operation details were collected and analyzed.

RESULTS

54 patients were included. The median time between primary repair and revision procedure was 25 months (IQR 13-95, range 0-250). The left-anterior quadrant was involved in 43 patients (80%), the right-anterior quadrant in 21 patients (39%), the left-posterior quadrant in 21 patients (39%), and the right-posterior quadrant in 10 patients (19%).

CONCLUSION

In this study, hiatal hernia recurrences occured most commonly at the left-anterior quadrant of the hiatus, however, posterior recurrences were not uncommon. Based on our results, we hypothesize that both posterior and anterior hiatal reinforcement might be a suitable solution to lower the recurrence rate of hiatal hernia. A randomized controlled trial using a circular, bio-absorbable mesh has been initiated to test our hypothesis.

Subtemporal Approach for the Treatment of Ruptured and Unruptured Distal Basilar Artery Aneurysms: Is There a Contemporary Use?

BACKGROUND AND OBJECTIVES

Distal basilar artery aneurysms (DBAs) are high-risk lesions for which endovascular treatment is preferred because of their deep location, yet indications for open clipping nonetheless remain. The subtemporal approach allows for early proximal control and direct visualization of critical posterior perforating arteries, especially for posterior-projecting aneurysms. Our objective was to describe our clinical experience with the subtemporal approach for clipping DBAs in the evolving endovascular era.

METHODS

This was a retrospective, single-institution case series of patients with DBAs treated with microsurgery over a 21-year period (2002-2023). Demographic, clinical, and surgical data were collected for analysis.

RESULTS

Twenty-seven patients underwent clipping of 11 ruptured and 16 unruptured DBAs with a subtemporal approach (24 female; mean age 53 years). Ten patients had expanded craniotomies for treatment of additional aneurysms. The aneurysm occlusion rate was 100%. Good neurological outcomes as defined by the modified Rankin Scale score ≤2 and Glasgow Outcome Scale score ≥4 were achieved in 21/27 patients (78%). Two patients died before hospital discharge, one from vasospasm-induced strokes and another from an intraoperative myocardial infarction.

CONCLUSION

These results demonstrate that microsurgical clip ligation of DBAs using the subtemporal approach remains a viable option for complex lesions not amenable to endovascular management.

Renal dysfunction in adults following cardiopulmonary bypass is linked to declines in S-nitroso hemoglobin: a case series

Background

Impaired kidney function is frequently observed in patients following cardiopulmonary bypass (CPB). Our group has previously linked blood transfusion to acute declines in S-nitroso haemoglobin (SNO-Hb; the main regulator of tissue oxygen delivery), reductions in intraoperative renal blood flow, and postoperative kidney dysfunction. While not all CPB patients receive blood, kidney injury is still common. We hypothesized that the CPB procedure itself may negatively impact SNO-Hb levels leading to renal dysfunction.

Materials and methods

After obtaining written informed consent, blood samples were procured immediately before and after CPB, and on postoperative day (POD) 1. SNO-Hb levels, renal function (estimated glomerular filtration rate; eGFR), and plasma erythropoietin (EPO) concentrations were quantified. Additional outcome data were extracted from the patients' medical records.

Results

Twenty-seven patients were enroled, three withdrew consent, and one was excluded after developing bacteremia. SNO-Hb levels declined after surgery and were directly correlated with declines in eGFR (R=0.48). Conversely, plasma EPO concentrations were elevated and inversely correlated with SNO-Hb (R=-0.53) and eGFR (R=-0.55). Finally, ICU stay negatively correlated with SNO-Hb concentration (R=-0.32).

Conclusion

SNO-Hb levels are reduced following CPB in the absence of allogenic blood transfusion and are predictive of decreased renal function and prolonged ICU stay. Thus, therapies directed at maintaining or increasing SNO-Hb levels may improve outcomes in adult patients undergoing cardiac surgery.

Curative Resection for Metastatic Solid Pseudopapillary Neoplasm of Pancreas-a Case Series

Solid pseudopapillary neoplasm (SPN) is an unusual tumor of the pancreas. Unlike ductal adenocarcinoma, SPN is commoner in young women and is indolent with better prognosis. Fifteen percent of patients, however, develop metastases, often synchronous and involving the liver or peritoneum. Owing to the paucity of cases, management of the metastatic disease is not clearly defined. Retrospective review of case notes of patients treated between 2006 and 2019. There were 53 patients with SPN of which 4 had hepatic metastases-3 synchronous and 1 metachronous. Two patients underwent simultaneous distal pancreatectomy and splenectomy with liver resection (right posterior sectionectomy and metastasectomy). One required right hepatectomy with metastasectomy for metachronous liver metastases. The other underwent a staged operation-remnant tumor excision with metastasectomy followed by right hepatectomy after portal vein embolization. All four patients are recurrence free on median follow-up of 38.5 months. In view of the excellent prognosis, we recommend radical resection of both the primary lesion and metastases for SPN.

Chylous ascites after associating liver partition and portal vein ligation for stage hepatectomy (ALPPS): overview and case report

Chylous ascites is an uncommon pathology with low incidence following hepato-pancreato-biliary surgery, there are no cases reported in the international literature following the associating liver partition and portal vein ligation for stage hepatectomy (ALPPS) procedure. It is caused by abnormal intraperitoneal accumulation of lymph fluid in the abdominal cavity secondary to obstruction or injury to the chyle cistern or its tributaries. We describe the case of a 49-year-old woman diagnosed with colon cancer and liver metastasis. ALPPS was performed, on a first and second stage, presenting a high drainage output as well as change in the characteristics of the drainage fluid. The diagnosis of chylous ascites was confirmed by finding triglyceride levels in the drainage fluid at 300 mg/dL. Medical treatment was started based on a hyper-protein diet and fat restriction, supplemented with medium-chain triglycerides and somatostatin analog, with fistula resolution. It can be managed with medical treatment.

Retroperitoneal laparoscopic partial nephrectomy with selective renal artery clamping for renal cell carcinoma: initial outcomes

Introduction

To explore the feasibility and safety of retroperitoneal laparoscopic partial nephrectomy (RLPN) with selective artery clamp (SAC) in patients with renal cell carcinoma (RCC).

Methods

The authors recruited three men and two women who underwent RLPN for T1 RCC between December 2022 and May 2023 at a tertiary hospital. The median age of the patients was 32 years (range, 25-70 years). The tumour size ranged from 3 to 4.5 cm. The R.E.N.A.L scores were 4x, 5p, 8a, 5a, and 8ah. The median preoperative eGFR was 96.9 (74.3-105.2). Renal computed tomography angiography was performed before the surgery to evaluate the artery branches. The operation time, number of clamped arteries, warm ischaemic time (WIT), intraoperative blood loss, RCC type, postoperative hospital stay, changes in renal function, and complications were evaluated. The follow-up duration was 6 months.

Results

The median operation time was 120 (75-150) minutes. One artery was clamped in four patients, while three were clamped in one patient. The median WIT was 22 (15-30) min, and the median blood loss was 150 (100-300) ml. No complications were recorded, and the resection margin was negative in all patients. The median decrease in eGFR was 6 (4-30%).

Conclusions

RLPN with SAC for T1 RCC is safe and feasible in clinical practice.

Clinico-radiological correlation with outcome in acute epidural haematoma: a tertiary centre experience from Nepal

Background

Epidural haematoma (EDH) accounts for up to 15% of severe traumatic brain injury (TBI) cases and remains the most common cause of mortality and disability. Several clinical and radiological factors affect patient outcomes. This study aims to correlate patients' clinical and radiological profiles with acute EDH outcomes.

Methods

A retrospective, single-centred, consecutive case series was conducted on the patients diagnosed with an acute EDH admitted to Tribhuvan University Teaching Hospital (TUTH) between May 2019 and April 2023. The modified Rankin scale (mRS) was used to assess the outcome. Univariate analysis and Kruskal-Wallis H test with Dunn-Bonferroni post-hoc test was conducted.

Results

There were 107 patients diagnosed with EDH, of which 52.3% were less than 20 years old with male preponderance. Falls were the most common mechanism of injury (64.5%), and most cases were referred to, not brought directly. The majority had a GCS score greater than or equal to 13 (85%) at presentation, and only 5.5% had a GCS score less than or equal to 8. According to the mRS, most patients had favourable outcomes, with 88.7% having no significant disability and 11.3% having a slight disability.

Conclusion

This case series is the largest and most recent report from Nepal and demonstrated that GCS, pupillary response, skull fracture, neurological symptoms, pre-hospital and intra-hospital delay, and management modalities are critical factors in determining the total hospital and ICU stay but did not have an impact on the mRS scores.

Technical Trick: Cryoneurolysis for Subacute Pain Mitigation in Patients With Limb Loss

SUMMARY

Pain after amputation is often managed by target muscle reinnervation (TMR) with the added benefit that TMR also provides improved myoelectric terminal device control. However, as TMR takes several months for the recipient muscles to reliably reinnervate, this technique does not address pain within the subacute postoperative period during which pain chronification, sensitization, and opioid dependence and misuse may occur. Cryoneurolysis, described herein, uses focused, extreme temperatures to essentially "freeze" the nerve, blocking nociception, and improving pain in treated nerves potentially reducing the chances of pain chronification, sensitization, and substance dependence or abuse.

Potato Peel Waste as an Economic Feedstock for PHA Production by Bacillus circulans

Polymers of hydroxy alkanoates (PHA), also known as biodegradable, biocompatible plastic, are potential alternatives to petrochemical-based plastics. PHA is synthesized by microbes in their cytoplasm in the form of inclusion bodies in stress conditions such as nitrogen, oxygen, and phosphorus with excessive amounts of carbon. Sugar extracted from potato peel in the form of hydrolysate was employed as a carbon source for PHA production after acidic hydrolysis. The acid hydrolysis conditions are optimized for dilute acid concentrations and temperatures. The highest sugar-yielding condition (2% 15 min at 121 ℃) was used for submerged fermentation for PHA production by Bacillus circulans MTCC 8167. Fourier transform infrared spectroscopy, nuclear magnetic resonance, and differential scanning calorimetry were used for polymer characterization. Gas chromatography coupled with mass spectrometry confirmed the monomers such as hexadecenoic acid 3-hydroxy, methyl esters, pentadecanoic acid 14 methyl esters, and tetradecanoic acid 12- methyl esters. Crotonic acid assay was used for quantification of PHA and it was found highest (0.232 ± 0.04 g/L) at 37 °C and 36 h of incubation. Hence, potato peel waste could be a potential feedstock for waste to valuable production.

Gamma knife radiosurgery for clival metastasis: case series and systematic review

PURPOSE

Clival metastatic cancer is rare and has limited literature to guide management. We describe management of clival metastasis with Gamma Knife radiosurgery (GKRS). We augment our findings with a systematic review of all forms of radiation therapy for clival metastasis.

METHODS

Records of 14 patients with clival metastasis who underwent GKRS at the University of Pittsburgh Medical Center from 2002 to 2023 were reviewed. Treatment parameters and clinical outcomes were assessed. A systematic review was conducted using evidence-based guidelines.

RESULTS

The average age was 61 years with male predominance (n = 10) and average follow-up of 12.4 months. The most common primary cancers were prostate (n = 3) and lung (n = 3). The average time from cancer diagnosis to clival metastasis was 34 months. The most common presenting symptoms were headache (n = 9) and diplopia (n = 7). Five patients presented with abducens nerve palsies, and two presented with oculomotor nerve palsies. The median tumor volume was 9.3 cc, and the median margin dose was 15 Gy. Eleven patients achieved tumor control after one procedure, and three with progression obtained tumor control after repeat GKRS. One patient recovered abducens nerve function. The median survival from cancer diagnosis and GKRS were 49.7 and 15.3 months, respectively. The cause of death was progression of systemic cancer in six patients, clival metastasis in one, and unknown in four. The systematic review included 31 studies with heterogeneous descriptions of treatment and outcomes.

CONCLUSION

Clival metastasis is rare and associated with poor prognosis. GKRS is a safe, effective treatment for clival metastasis.

Preservation of cranial nerve function in large and giant trigeminal schwannoma resection: a case series

BACKGROUND

Trigeminal schwannomas (TSs) are intracranial tumors that can cause significant brainstem compression. TS resection can be challenging because of the risk of new neurologic and cranial nerve deficits, especially with large (≥ 3 cm) or giant (≥ 4 cm) TSs. As prior surgical series include TSs of all sizes, we herein present our clinical experience treating large and giant TSs via microsurgical resection.

METHODS

This was a retrospective, single-surgeon case series of adult patients with large or giant TSs treated with microsurgery in 2012-2023.

RESULTS

Seven patients underwent microsurgical resection for TSs (1 large, 6 giant; 4 males; mean age 39 ± 14 years). Tumors were classified as type M (middle fossa in the interdural space; 1 case, 14%), type ME (middle fossa with extracranial extension; 3 cases, 43%), type MP (middle and posterior fossae; 2 cases, 29%), or type MPE (middle/posterior fossae and extracranial space; 1 case, 14%). Six patients were treated with a frontotemporal approach (combined with transmastoid craniotomy in the same sitting in one patient and a delayed transmaxillary approach in another), and one patient was treated using an orbitofrontotemporal approach. Gross total resection was achieved in 5 cases (2 near-total resections). Five patients had preoperative facial numbness, and 6 had immediate postoperative facial numbness, including two with worsened or new symptoms. Two patients (28%) demonstrated new non-trigeminal cranial nerve deficits over mean follow-up of 22 months. Overall, 80% of patients with preoperative facial numbness and 83% with facial numbness at any point experienced improvement or resolution during their postoperative course. All patients with preoperative or new postoperative non-trigeminal tumor-related cranial nerve deficits (4/4) experienced improvement or resolution on follow-up. One patient experienced tumor recurrence that has been managed conservatively.

CONCLUSIONS

Microsurgical resection of large or giant TSs can be performed with low morbidity and excellent long-term cranial nerve function.

The Role of Psychosomatic Traits in Tailored Workup for Anterior Cervical Discectomy and Fusion-A Case Series

STUDY DESIGN

Prospective study.

OBJECTIVE

To evaluate the influence of preoperatively assessed psychosomatic traits on postoperative pain, disability, and quality of life outcomes.

SUMMARY OF BACKGROUND DATA

Anterior cervical discectomy and fusion (ACDF) is a widely employed surgical procedure for treating cervical spondylosis. Despite its effectiveness, various studies have reported non-success rates in terms of alleviating disability and pain. Psychological factors have become increasingly recognized as critical determinants of surgical outcomes in various medical disciplines. The full extent of their impact within the context of ACDF remains insufficiently explored. This case series aims to assess the influence of preoperative psychological profiling on long-term pain, disability and quality of life outcomes.

METHODS

We conducted a prospective cohort study of prospectively collected data from 76 consecutive patients who underwent ACDF with PEEK inter-fixed cages from July 2019 to November 2021. The preoperative psychological traits were assessed using the Symptom Checklist 90 (SCL-90) questionnaire. The Oswestry Disability Index (ODI), Visual Analogue Scale (VAS), Neck Disability index (NDI), EuroQol-5D (EQ-5D), and Short Form-36 (SF-36) were collected preoperatively, one month postoperatively, and at least one year after the surgical procedure.

RESULTS

The correlation analyses revealed associations between psychosomatic traits and multiple preoperative and postoperative outcome measures. The univariate analyses and linear regression analyses demonstrated the influence of the Global Severity Index (GSI) over the final follow-up scores for the ODI, VAS, NDI, EQ-5D, and SF-36. The GSI consistently exhibited a stronger correlation with the final follow-up pain, disability, and quality of life outcomes with respect to the correspondent preoperative values.

CONCLUSION

This study highlights the importance of psychosomatic traits as predictive factors for ACDF outcomes and emphasizes their relevance in preoperative assessment for informing patients about realistic expectations. The findings underscore the need to consider psychological profiles in the preoperative workup, opening avenues for research into medications and psychological therapies. Recognizing the influence of psychosocial elements informs treatment strategies, fostering tailored surgical approaches and patient care.

The role of surgical disconnection for posterior fossa pial arteriovenous fistulas and dural fistulas with pial supply: an illustrative case series

BACKGROUND

Pial arteriovenous fistulas (pAVFs) are rare vascular malformations characterized by high-flow arteriovenous shunting involving a cortical arterial supply directly connecting to venous drainage without an intermediate nidus. Dural arteriovenous fistulas (dAVFs) can infrequently involve additional pial feeders which can introduce higher flow shunting and increase the associated treatment risk. In the posterior fossa, arteriovenous fistula (AVF) angioarchitecture tends to be particularly complex, involving either multiple arterial feeders-sometimes from both dural and pial origins-or small caliber vessels that are difficult to catheterize and tend to be intimately involved with functionally critical brainstem or upper cervical cord structures. Given their rarity, published experience on microsurgical or endovascular treatment strategies for posterior fossa pAVFs and dAVFs with pial supply remains limited.

METHODS

Retrospective chart review from 2019-2023 at a high-volume center identified six adult patients with posterior fossa pAVFs that were unable to be fully treated endovascularly and required microsurgical disconnection. These cases are individually presented with a technical emphasis and supported by comprehensive angiographic and intraoperative images.

RESULTS

One vermian (Case 1), three cerebellopontine angle (Cases 2-4) and two craniovertebral junction (Cases 5-6) posterior fossa pAVFs or dAVFs with pial supply are presented. Three cases involved mixed dural and pial arterial supply (Cases 1, 4, and 6), and one case involved a concomitant microAVM (Case 2). Endovascular embolization was attempted in four cases (Cases 1-4): The small caliber and tortuosity of the main arterial feeder prevented catheterization in two cases (Cases 1 and 3). Partial embolization was achieved in Cases 2 and 4. In Cases 5 and 6, involvement of the lateral spinal artery or anterior spinal artery created a prohibitive risk for endovascular embolization, and surgical clip ligation was pursued as primary management. In all cases, microsurgical disconnection resulted in complete fistula obliteration without evidence of recurrence on follow-up imaging (mean follow-up 27.1 months). Two patients experienced persistent post-treatment sensory deficits without significant functional limitation.

CONCLUSIONS

This illustrative case series highlights the technical difficulties and anatomical limitations of endovascular management for posterior fossa pAVFs and dAVFs with pial supply and emphasizes the relative safety and utility of microsurgical disconnection in this context. A combined approach involving partial preoperative embolization-when the angioarchitecture is permissive-can potentially decrease surgical morbidity. Larger studies are warranted to better define the role for multimodal intervention and to assess associated long-term AVF obliteration rates in the setting of pial arterial involvement.

Systemic Inflammation Response Index (SIRI) and Monocyte-to-Lymphocyte Ratio (MLR) Are Predictors of Good Outcomes in Surgical Treatment of Periprosthetic Joint Infections of Lower Limbs: A Single-Center Retrospective Analysis

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication that develops after total joint arthroplasty (TJA), whose incidence is expected to increase over the years. Traditionally, surgical treatment of PJI has been based on algorithms, where early infections are preferably treated with debridement, antibiotics, and implant retention (DAIR) and late infections with two-stage revision surgery. Two-stage revision is considered the "gold standard" for treatment of chronic prosthetic joint infection (PJI) as it enables local delivery of antibiotics, maintenance of limb-length and mobility, and easier reimplantation. Many studies have attempted to identify potential predicting factors for early diagnosis of PJI, but its management remains challenging. In this observational retrospective study, we investigated the potential role of inflammatory blood markers (neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), systemic inflammatory response index (SIRI), and aggregate index of systemic inflammation (AISI)) as prognostic factors in two-stage exchange arthroplasty for PJI.

METHODS

A single-center retrospective analysis was conducted, collecting clinical data and laboratory parameters from patients submitted to prosthetic explantation (EP) for chronic PJI. Laboratory parameters (PCR, NLR, MLR, PLR, SIRI, SII, and AISI) were evaluated at the explantation time; at 4, 6, and 8 weeks after surgery; and at reimplantation time. The correlation between laboratory parameters and surgery success was evaluated and defined as infection absence/resolution at the last follow-up.

RESULTS

A total of 57 patients with PJI were evaluated (62% males; average age 70 years, SD 12.14). Fifty-three patients with chronic PJI were included. Nine patients underwent DAIR revision surgery and chronic suppressive therapy; two patients died. Nineteen patients completed the two-stage revision process (prosthetic removal, spacer placement, and subsequent replanting). Among them, none showed signs of reinfection or persistence of infection at the last available follow-up. The other twenty-three patients did not replant due to persistent infection: among them, some (the most) underwent spacer retention; others (fewer in number) were submitted to resection arthroplasty and arthrodesis (Girdlestone technique) or chronic suppressive antibiotic therapy; the remaining were, over time, lost to follow-up. Of the patients who concluded the two-stage revision, the ones with high SIRI values (mean 3.08 SD 1.7 and p-value 0.04) and MLR values (mean 0.4 SD 0.2 and p-value 0.02) at the explantation time were associated with a higher probability of infection resolution. Moreover, higher variation in the SIRI and PCR, also defined, respectively, as delta-SIRI (mean -2.3 SD 1.8 and p-value 0.03) and delta-PCR (mean -46 SD 35.7 and p-value 0.03), were associated with favorable outcomes.

CONCLUSIONS

The results of our study suggest that, in patients with PJI undergoing EP, the SIRI and MLR values and delta-SIRI and delta-PCR values could be predictive of a favorable outcome. The evaluation of these laboratory indices, especially their determination at 4 weeks after removal, could therefore help to determine which patients could be successfully replanted and to identify the best time to replant. More studies analyzing a wider cohort of patients with chronic PJI are needed to validate the promising results of this study.

Maxillary sinus augmentation via the bone lid technique: A prospective, radiographic case series

BACKGROUND

Maxillary sinus augmentation is one of the most performed procedures to increase the bone quantity of the atrophic maxilla to allow implant placement. The aim of the present case series was to describe a surgical protocol to perform maxillary sinus augmentation with the "bone lid technique," and its outcomes in a cohort of patients eligible for the procedure.

METHODS

After the initial clinical evaluation, a cone-beam computed tomography (CBCT) examination was performed for preoperative assessment. Patients were then scheduled for surgical intervention. At 6-9 months follow-up, patients underwent a second CBCT scan to evaluate bone height following bone graft and to schedule implant placement.

RESULTS

A total of 11 patients were enrolled in the study with a total of 13 sinus lift procedures. Membrane perforation was registered in 4 cases (30.76%). Mean surgical time was 67.69 min (SD 6.51). Postoperative period was uneventful in all patients, in the absence of complications. The mean graft volume increase was 2.46 cm3 (SD 0.85), and the mean height increase was 14.27 mm (SD 3.18). Mean membrane thickness was 1.40 mm (SD 0.75). In all the 4 cases with sinus membrane perforation, the membrane had a thickness lower than 1 mm.

CONCLUSIONS

The present study highlights that the maxillary sinus augmentation with bone lid repositioning could provide repeatable results in terms of bone height increase. The technique appears reliable both in terms of bone gain and absence of complications.

KEY POINTS

The bone lid technique for maxillary sinus augmentation provides repeatable results in terms of bone height increase. The favorable clinical outcomes can be related to an enhancement of bone formation due to the unique osteoconductive and osteoinductive properties of autogenous bone, along with a reduction of soft tissue ingrowth. Complications were not observed in any of the patients following the surgical procedures. The risk of Schneiderian membrane perforation is inversely proportional to membrane thickness; the thinner the membrane is, the higher the risk to perforate it.

COVID-19 related peripheral arterial thrombotic events in intensive care unit and non-intensive care unit patients: A retrospective case series

OBJECTIVES

COVID-19 associated arterial thrombosis has been attributed to multiple inflammation and coagulation mechanisms. The aim of this study was to report the experience of a tertiary center on COVID-19 patients managed for acute peripheral arterial thrombosis.

METHODS

A single-center case series was conducted, including retrospectively collected data from all COVID-19 patients presenting arterial thrombosis, from March 2020 to February 2022. Intensive care unit (ICU) and non-ICU cases were included. The primary outcomes were mortality, successful revascularization, and amputation at 30 days.

RESULTS

Twenty patients presented peripheral arterial thrombosis (90% males, mean age 65 years (16-82 years)). Eighteen were diagnosed with the Delta variant and none was previously vaccinated. All cases presented acute lower limb ischemia; in 20% with bilateral involvement. Nine patients were hospitalized in the ward while 11 in the ICU. From the non-ICU cases, five presented Rutherford IIb and four cases, Rutherford's IIa ischemia. Six cases underwent revascularization (67%). Two of them were finally amputated (33%) and two died during hospitalization (33%). Two revascularizations were considered successful (33%). The ICU group presented mainly with Rutherford's III ischemia (54.5%). The mortality in the ICU cohort was 72.7%. Only one patient underwent successful revascularization and two were amputated in this subgroup. Early mortality was 50% for the total cohort while the type of management was not related to mortality.

CONCLUSIONS

Covid-19 related arterial thrombosis in non-vaccinated population is associated with 50% early mortality; increased up to 72% in the ICU patients. The amputation rate was 20% while only 40% of the revascularizations were considered successful.

Interhemispheric Vertical Hemispherotomy: Technique, Outcome, and Pitfalls-A Bicentric Retrospective Case Series of 39 Cases

BACKGROUND AND OBJECTIVES

When seizure onset affects a whole hemisphere, hemispheric disconnections are efficient and safe procedures. However, both lateral peri-insular hemispherotomy and vertical paramedian hemispherotomy approaches report a failure rate around 20%, which can be explained by residual connections giving rise to persistent seizures. In this study, we present the interhemispheric vertical hemispherotomy (IVH), a technical variation of the vertical paramedian hemispherotomy approach, that aims to increase seizure control avoiding residual connections while exposing the corpus callosum.

METHODS

This is a retrospective study of IVH in two centers, with analysis of clinical and MRI data and outcomes. A detailed description of the technique is provided with a video.

RESULTS

IVH was performed in 39 children. The mean age at surgery was 7.2 years, and etiologies were as follows: malformations of cortical development (n = 14), Rasmussen's encephalitis (n = 10), stroke (n = 10), post-traumatic (3), and Sturge-Weber Syndrome (2). Hemispheric disconnection was complete on postoperative MRI in 34 cases. There was no mortality, hydrocephalus occurred in one case, and subdural collection occurred in four cases. A second surgery was performed in four cases because of seizure relapse (n = 3) and/or incomplete disconnection on MRI (n = 4). With a mean follow-up of 3.2 years, International League Against Epilepsy class I epilepsy outcome was obtained for 37/39 patients.

CONCLUSION

IVH is a safe and effective variation of the vertical approaches for hemispheric disconnection. It allows a good exposure and anatomic control of the corpus callosum, which is a frequent site of incomplete disconnection. IVH may be limited by the thalamic volume and the ventricular size, notably in hemimegalencephaly cases.

Changes in lower urinary tract function after minimally invasive nerve-sparing for complete excision of endometriosis: An observational study

OBJECTIVES

The objective of this paper is to evaluate changes in lower urinary tract symptoms (LUTS), severity of pain and urodynamic parameters after minimally invasive nerve-sparing surgery for patients with endometriosis.

METHODS

We analyzed 143 patients undergoing minimally invasive nerve-sparing surgery for endometriosis excision (laparoscopy/robot-assisted). The endometriosis was confirmed by preoperative clinical evaluation, magnetic resonance imaging (MRI) showing at least one lesion deeper than 5 mm, and histological confirmation after laparoscopy. We evaluated three points prior and after surgery: LUTS parameters according to the International Urogynecological Association; urodynamic measures of storage and voiding and the severity of the dyspareunia, dyschezia and dysmenorrhea assessed on a self-reported 11-point numeric rating scale. The Wilcoxon signed rank and McNemar tests were used for statistical analyses (p < 0.05).

RESULTS

We observed significant improvements in LUTS after the surgery with postoperative symptom-free probabilities in urgency (64.5%), daytime frequency (38.5%), and dysuria (87.1%). However, slow stream prevalence increased significantly postsurgery (p = 0.022), with a 20.5% risk of asymptomatic patients developing this symptom. Urodynamic responses varied; for instance, maximum cystometric capacity improved significantly (p = 0.004), while postvoiding residual worsened (p = 0.006). Significant worsening in postvoiding residual occurred in women with normal preoperative values (p = 0.002), with a 17.7% risk of normal values becoming abnormal. Compliance or maximum cystometric capacity not considered normal preoperatively showed significant improvements (p < 0.001), but the risk of normal values becoming abnormal after surgery was 14.5%.

CONCLUSION

The minimally invasive nerve-sparing surgery for endometriosis excision shows improvement in lower urinary tract symptoms, urodynamics parameters and severity of pain. The majority of patients became asymptomatic in the postoperative period. When compared to the benefits of the patients' surgical treatment, particularly when considering the reduction of pain, the risks of the lower urinary tract treatment seem to be acceptable. The surgical intervention seems to be a safe alternative in patients with endometriosis, although studies with larger samples are needed to confirm these findings.

Colorectal procedures with the novel Hugo™ RAS system: training process and case series report from a non-robotic surgical team

BACKGROUND

The landscape of robotic surgery is evolving with the emergence of new platforms. However, reports on their applicability in different surgical fields are still limited and come from teams with robotics experience. This study aims to describe the training process for colorectal surgery with the Hugo™ RAS system of a robotics-inexperienced surgical team and present the initial patient series.

METHODS

The training process is depicted, and data from the first 10 consecutive patients operated on for colorectal conditions with the Hugo™ RAS system by a surgical team with no prior experience in robotic surgery were prospectively recorded and analysed.

RESULTS

The team received intensive training in robotic surgery and specifically in the Hugo™ RAS system previously to the first case. Between May 2023 and December 2023, 10 patients underwent colorectal procedures: 5 right colectomies, 3 sigmoid resections, 1 high rectal resection and 1 ventral mesh rectopexy. The first case was proctored by an expert. Median docking time was 14 min and median total operative time was 185 min. The only technical difficulty during the procedures was occasional clashing of robotic arms. None had to be converted, and no intraoperative or postoperative morbidity was recorded. Hospital stays ranged from 2 to 4 days. A median of 21 lymph nodes were yielded in the operations for malignant conditions.

CONCLUSIONS

Common colorectal procedures can be safely performed using the Hugo™ RAS platform. Prior experience in robotic surgery is not a necessary requirement, but following a structured training program is essential.

Digital 3D Exoscope is Safe and Effective in Surgery for Intradural Extramedullary Tumors: A Comparative Series

BACKGROUND

Digital 3D exoscopes have been shown to be comparably safe and effective as surgical microscopes in complex microneurosurgical procedures. However, the results of exoscopic spinal tumor surgeries are scarce. The purpose of this study is to compare results of a transition from microscope to exoscope in surgeries for spinal intradural extramedullary tumors.

METHODS

We included all consecutive patients with intradural extramedullary spinal tumors operated on by the senior author during January 2016 to October 2023. The 3D exoscope was used in the latter half of the series from November 2020. We evaluated pre- and postoperative clinical findings, imaging studies, intra- and postoperative events, and analyzed surgical videos from the operations retrospectively.

RESULTS

We operated 35 patients (exoscope n = 19, microscope n = 16) for intradural extramedullary tumors (meningioma n = 18, schwannoma n = 12, other n = 5). Tumors in the cervical and thoracic spine were more common than in the lumbar region. The duration of surgery was slightly longer (median 220 vs. 185 minutes) in the exoscope group. However, the rate of gross total resection of the tumor was higher (81% vs. 67%) and the tumors more often located anteriorly to the spinal cord (42% vs. 13%) in the exoscope group. No major complications (i.e., permanent motor deficit or postoperative hematoma) occurred in either group. We saw postoperative gait improvement in 81% and 85% of the patients with preoperative deterioration of gait after exoscopic and microscopic surgeries, respectively.

CONCLUSIONS

This study demonstrates that exoscope-assisted surgery for spinal intradural extramedullary tumors is comparable in safety and effectiveness to traditional microscopic surgery.

Endoscopic endonasal approach for olfactory groove meningioma resection: Strategies and outcomes in a retrospective case series

OBJECTIVE

Though the endoscopic endonasal approach (EEA) is a widely accepted treatment for skull base tumors, the specific use of EEA for olfactory groove meningiomas (OGMs) is debated, with variable outcomes reported in the literature. We review the surgical results of OGM resections for one surgeon including the operative approach, surgical nuances, and outcomes, with a focus on factors relating to patient selection which favor EEA over transcranial approaches.

METHODS

We retrospectively reviewed thirteen cases of endoscopic endonasal resection of olfactory groove meningiomas. Patient characteristics, clinical characteristics, surgical outcomes, and complications were analyzed. Extent of resection was determined based on volumetric analysis of pre- and postoperative MRI.

RESULTS

Anatomic characteristics that render a tumor difficult to access fully are lateral extension beyond the mid-orbit and anterior extension to the falx. Simpson Grade I resection was achieved in 11/13 (84.6 %) cases. Mean pre-operative tumor volume was 8.99 cm3 (range 2.19-16.79 cm3), and 92 % of tumors were WHO grade I. We demonstrate 2 cases of smell preservation, possible with small unilateral tumors and tumors that are confined to either the anterior or posterior portion of the cribriform plate. The post-operative CSF leak rate was 7.7 %, without prophylactic lumbar CSF drainage. The mortality rate was 7.7 % (n = 1) after infectious complications following CSF leak.

CONCLUSIONS

Endoscopic endonasal resection of olfactory groove meningiomas is an effective and safe operative method with outcomes and complication rates comparable to transcranial approaches. Key considerations include careful patient selection and familiarity with technical nuances of endoscopic endonasal approach for this specific tumor type.

Objective and owner-reported outcomes after modified cranial closing wedge ostectomy: a case series

Immediate and longer-term outcomes of a cranial closing wedge ostectomy variant for management of canine cranial cruciate ligament disease were assessed in this single-center retrospective consecutive study. Records and radiographs were retrieved and assessed by three independent observers to evaluate tibial plateau angle, anatomical-mechanical axis angle, tibial tuberosity distalization, and mechanical axis length before and after surgery. Kinetic gait analysis and owner questionnaires were used to assess clinical outcomes. Seventeen stifles from fifteen dogs were evaluated radiographically. Mean error from target tibial plateau angle was 0.4 degrees. Anatomical-mechanical axis angles reduced from mean 2.9 degrees preoperatively to mean - 0.9 degrees postoperatively. Tibial tuberosity distalization was mean 5.0% of mechanical axis length, and mean reduction in mechanical axis length was 0.1%. Increased tibial plateau angles were noted in 8/17 stifles, with a mean of 9.6 degrees at short-term follow-up. Major complications were observed in 9/17 stifles. Long term follow-up (mean 832 days) was obtained with gait analysis in 8/15 dogs and with questionnaire in 11/15. Most dogs (9/11) were weakly to moderately affected by osteoarthritis symptoms. All values for peak vertical force and vertical impulse normalized to body weight exceeded local lower reference limits for normal dogs, indicating acceptable limb use. Satisfactory immediate and long-term clinical outcomes appear to be possible with this technique, but the high incidence of shorter-term complications may caution against the technique or the fixation and management described here.

Three-Vessel Anastomosis for Direct Multiterritory Cerebral Revascularization: Case Series

BACKGROUND AND OBJECTIVE

Cerebral revascularization of multiple territories traditionally requires multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. A novel 3-vessel anastomosis technique allows for direct, simultaneous multiterritory cerebral revascularization using a single interposition graft. We herein present our experience with this approach.

METHODS

Retrospective review of perioperative data and outcomes for patients undergoing multiterritory cerebral revascularization using a 3-vessel anastomosis from 2019 to 2023.

RESULTS

Five patients met inclusion criteria (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery aneurysms (1 ruptured) were treated with proximal ligation or partial/complete clip trapping and multiterritory external carotid artery-M2-M2 revascularization using a saphenous vein interposition graft. Two patients with moyamoya disease, prior strokes, and predominately bilateral anterior cerebral artery hypoperfusion were treated with proximal superficial temporal artery-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap graft. No patients experienced significant surgery-related ischemia. Bypass patency was 100%. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for subdural hematoma evacuation and radial artery fascial flow-through free flap debridement, without affecting bypass patency or neurologic outcome. On hospital discharge, median Glasgow Outcome Scale and modified Rankin Scale scores were 4 (range 3-5) and 2 (range 0-5), respectively. On follow-up, 1 patient died from medical complications of their presenting stroke; Glasgow Outcome Scale and modified Rankin Scale scores were otherwise stable or improved.

CONCLUSION

The 3-vessel anastomosis technique can be considered for simultaneous revascularization of multiple intracranial territories.

Enhancing root coverage and esthetic outcomes in isolated gingival recession using orthodontic intervention and lateral closed tunnel technique: An interdisciplinary prospective case series

BACKGROUND

Gingival recession (GR) in malposed tooth in association with bone dehiscence and/or fenestration poses a challenge for successful root coverage treatment. Lateral closed tunnel (LCT) technique is particularly useful in isolated GR in mandibular anterior region, where the shallow vestibular depth prevents tension-free coronal mobilization of tissues.

METHODS

Twenty patients with GR associated with tooth malposition were treated using a combined orthodontic-periodontic approach with a torquing auxiliary spring followed by LCT technique.

RESULTS

The two techniques resulted in a combined recession depth reduction from 3.75 ± 1.14 mm to 0.40 ± 0.50 mm at the end of 6-month study period. The orthodontic intervention led to an increase in labial marginal bone levels, as assessed through cone beam computed tomography (CBCT), while the LCT achieved closure of residual recession defect. Also, an increase of keratinized tissue width from 0.81 ± 0.88 mm at baseline to 3.30 ± 0.67 mm at 6 months was achieved. Mean root coverage percentage (MRC%) of 91.40% + 10.25% was seen, with 11 out of 20 sites (55%) showing complete root coverage (CRC).

CONCLUSIONS

Single tooth orthodontic repositioning followed by LCT technique proved effective in successfully managing isolated recession defects in the mandibular anterior gingival region, which often presents challenging mucogingival conditions. The precise single tooth repositioning resulted in labial marginal bone augmentation, while the LCT surgical approach allowed residual defect closure.

KEY FINDINGS

Why are these cases new information? Correction of single tooth malposition is achieved before recession coverage treatment to achieve a favorable environment for graft uptake. The reduction in denuded root surface along with the bone remodeling results in increasing the ratio of vascular to avascular region, thus improving the overall prognosis of the treatment. What are the keys to successful management of these cases? The lateral closed tunnel technique involves creating a mucoperiosteal tunnel to close the recession site. Precision is crucial to avoid damage to surrounding tissues. The recipient site should be wider than the width of recession to improve graft vascularity. What are the primary limitations to success in these cases? Limitations may arise when dealing with complex cases, such as multiple teeth involvement or teeth with significant vertical or horizontal bone loss.

Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction: A case report and review of literature

BACKGROUND

Mycobacterium tuberculosis (TB) is the causative agent of TB, a chronic granulomatous illness. This disease is prevalent in low-income countries, posing a significant global health challenge. Gastrointestinal TB is one of the three forms. The disease can mimic other intra-abdominal conditions, leading to delayed diagnosis owing to the absence of specific symptoms. While gastric outlet obstruction (GOO) remains a frequent complication, its incidence has declined with the advent of proton pump inhibitors and Helicobacter pylori eradication therapy. Gastroduodenal TB can cause upper gastrointestinal hemorrhage, obstruction, and malignancy-like tumors.

CASE SUMMARY

A 23-year-old male presented with recurrent epigastric pain, distension, nausea, vomiting, and weight loss, prompting a referral to a gastroenterologist clinic. Endoscopic examination revealed distorted gastric mucosa and signs of chronic inflammation. However, treatment was interrupted, possibly owing to vomiting or comorbidities such as human immunodeficiency virus infection or diabetes. Subsequent surgical intervention revealed a dilated stomach and diffuse thickening of the duodenal wall. Resection revealed gastric wall effacement with TB.

CONCLUSION

Primary gastric TB is rare, frequently leading to GOO. Given its rarity, suspicions should be promptly raised when encountering relevant symptoms, often requiring surgical intervention for diagnosis and treatment.

Lateral-PLIF for spinal arthrodesis: concept, technique, results, complications, and outcomes

BACKGROUND

Posterior lumbar interbody fusion (PLIF) surgery represents an effective option to treat degenerative conditions in the lumbar spine. To reduce the drawbacks of the classical technique, we developed a variant, so-called Lateral-PLIF, which we then evaluated through a prospective consecutive series of patients.

METHODS

All adult patients treated at our institute with single or double level Lateral-PLIF for lumbar degenerative disease from January to December 2017 were prospectively collected. Exclusion criteria were patients < 18 years of age, traumatic patients, active infection, or malignancy, as well as unavailability of clinical and/or radiological follow-up data. The technique consists of insert the cages bilaterally through the transition zone between the central canal and the intervertebral foramen, just above the lateral recess. Pre- and postoperative (2 years) questionnaires and phone interviews (4 years) assessed pain and functional outcomes. Data related to the surgical procedure, postoperative complications, and radiological findings (1 year) were collected.

RESULTS

One hundred four patients were selected for the final analysis. The median age was 58 years and primary symptoms were mechanical back pain (100, 96.1%) and/or radicular pain (73, 70.2%). We found a high fusion rate (95%). A statistically significant improvement in functional outcome was also noted (ODI p < 0.001, Roland-Morris score p < 0.001). Walking distance increased from 812 m ± 543 m to 3443 m ± 712 m (p < 0.001). Complications included dural tear (6.7%), infection/wound dehiscence (4.8%), and instrument failure (1.9%) but no neurological deterioration.

CONCLUSIONS

Lateral-PLIF is a safe and effective technique for lumbar interbody fusion and may be considered for further comparative study validation with other techniques before extensive use to treat lumbar degenerative disease.

"One-and-a-Half" Interdural Transcavernous Pituitary Transposition/Rotation for Protection of Hypophyseal Portal System in Adult Peripheral Retroinfundibular Craniopharyngioma

BACKGROUND AND OBJECTIVES

Craniopharyngiomas originate from the pituitary stalk (PS) and extend along the pituitary-hypothalamic axis. Peripheral retroinfundibular craniopharyngiomas, particularly, may have worse surgery outcomes than other types. This study aims to investigate the advantage of using "one-and-a-half" interdural transcavernous pituitary transposition/rotation to dissect the tumor from the residual stalk and hypophyseal portal system for this subtype of craniopharyngioma.

METHODS

From August 2018 to February 2023, patients with peripheral retroinfundibular craniopharyngioma underwent surgical treatment. We analyzed clinical information, surgical records, imaging, and examination findings. The surgical procedure, including "one-and-a-half" interdural transcavernous pituitary transposition and rotation, was explained. Postoperative follow-up included endocrinological tests, MRI examinations, and urination surveys.

RESULTS

Among the 52 patients diagnosed with craniopharyngioma who underwent surgical treatment, 9 were classified as peripheral retroinfundibular craniopharyngioma, and they received "one-and-a-half" interdural transcavernous pituitary transposition and stalk rotation. In 6 cases, the residual PS and most of the hypophyseal portal system were preserved. Gross total resection was achieved in 5 patients and near total resection in 1 patient. One patient had a transection of the bilateral inferior hypophyseal arteries and 5 unilaterally. None experienced permanent diabetes insipidus, but varying degrees of anterior pituitary dysfunction postoperatively required hormone replacement therapy, which gradually decreased over time.

CONCLUSION

The natural anatomic corridor, "one-and-a-half" interdural transcavernous pituitary transposition, and stalk rotation provide increased working space compared with intradural or extradural pituitary transposition. Simultaneously rotating the tumor and pituitary enables a specific attack angle for lesion dissection after the anteriorly displaced residual stalk is rotated laterally. This approach preserves the residual PS and hypophyseal portal system, avoiding complications of diabetes insipidus and hypopituitarism. In most cases, only one side of the inferior hypophyseal artery needs to be sacrificed, ensuring normal pituitary function.

Empty sella in somatotropic pituitary adenomas; a series of 23 cases

Purpose

We aimed to investigate empty sella syndrome in somatotrophic pituitary adenoma for possible etiology, complications, and treatment options.

Method

Among over 2,000 skull base masses that have been managed in our center since 2013, we searched for growth hormone-producing adenomas. Clinical, surgical, and imaging data were retrospectively collected from hospital records to check for sella that lacked pituitary tissue on routine imaging.

Result

In 220 somatotrophic adenomas, 23 patients had an empty sella with surgical and follow-up data. The mean age of the sample was 46 years with the same male-to-female ratio. Five cases had partial empty sella and the rest were complete empty sellas. The most common simultaneous hormonal disturbance was high prolactin levels. Six had adenoma invasion into the clivus or sphenoid sinus and 10 had cavernous sinus intrusion. Peri-operative low-flow and high-flow cerebrospinal fluid (CSF) leaks were encountered in one and two patients, respectively, which were successfully sealed by abdominal fat. The majority of cases required growth hormone replacement therapy while it was controlled without any replacement therapy in nine patients. No pituitary hormonal disturbance occurred after transsphenoidal surgery except for hypothyroidism in one patient.

Conclusion

An empty sella filled with fluid can be detected frequently in pituitary adenomas, especially in the setting of acromegaly. The pituitary gland may be pushed to the roof of the sella and might be visible as a narrow rim on imaging or may be detected in unusual places out of the sella. The pathophysiology behind such finding originates from soft and hard tissue changes and CSF pressure alternations during abundant growth hormone production.

Outcomes of Dual Mobility Bearings in Revision Total Hip Replacements

Background Dual mobility bearings have gained attention in the prevention of instability in revision total hip replacement. This study aimed to evaluate the use of dual mobility bearings in revision total hip replacement. The primary outcome was the rate of dislocation. Secondary outcomes included the rate of re-operation for any reason, surgical complications, serious medical adverse events, and 90-day mortality rate. Methods A single-centre case series of 55 consecutive operations in 49 patients who underwent revision total hip replacement using dual mobility bearings with a minimum follow-up of three months was studied.  Results Early dislocation occurred in one case (2%), and there were no intra-prosthetic dislocations at a mean follow-up of 16 months. The rate of re-operation for any reason was 6/55 (11%) cases, and the post-operative infection rate was 2/55 (4%) cases. Serious medical adverse events occurred in 2/55 (4%) cases. The 90-day mortality rate was 1/55 (2%) cases. Two cases (2%) had cup abduction or anteversion angles outside of the safe zones although there were no dislocations in these patients. Conclusion This case series demonstrates a low dislocation rate in the early post-operative period for dual mobility bearings in revision total hip replacement. Dual mobility bearings show promise as an early low dislocation implant in revision total hip replacement. It remains to be determined whether dual mobility bearings are low-wear implants in the long term.

Assessment of drug prescription practises in chronic hemodialysis patients: case series

Introduction

The aim of the study was to assess the quality of drugs prescriptions in chronic haemodialysis patients.

Material and methods

The authors conducted a prospective study in chronic haemodialysis patients of two haemodialysis centres in the city of Oujda eastern Morocco, during the year of 2020. The authors identified the drugs prescribed in this population with regards to the product characteristics, in terms of indications, contraindications, dosage and drug interactions. Our data were analyzed by SPSS version 27 software.

Results

The mean number of drugs taken per patient was 8.15±6. Ninety-three percent of patients received treatment for anaemia. Phosphocalcic disorders and hypertension were treated in 89% and 72% of patients, respectively. In 77.6% of the cases, these drugs were taken orally. According to Vidal, the majority of prescriptions met the criteria of good prescription, in 81.54% of the cases, versus 18.46% of the patients with at least one of non-compliant prescription. On the other hand, 6.15% of the patients had at least one inadvisable combination. No contraindicated association was noted in our patients.

Conclusion

Patients undergoing haemodialysis have a higher risk of developing side effects and drug interactions than patients with normal kidney function. Given the paucity of pharmacokinetic studies in this population, nephrologists refer to their own experience to treat his patients effectively.Therapeutic education and regular monitoring of chronic haemodialysis patients can improve clinical outcomes, quality of life and reduce the cost of care.

Robotic Heller's myotomy using the new Hugo™ RAS system: first worldwide report

BACKGROUND

Achalasia is a rare disorder of the esophagus characterized by motor dysfunction in the esophagus and relaxation failure of the lower esophageal sphincter (LES). Currently, surgical myotomy procedures are considered the standard of care. Robotic Heller's myotomy (RHM) with fundoplication has been gaining popularity due to documented advantages in the precision of myotomy as well as avoiding the potential reflux following per-oral endoscopic myotomy (POEM). To the best of our knowledge, RHM has thus far has been performed exclusively by the da Vinci surgical system. The new Hugo RAS™ system offers a unique modular design and an open console which offers better maneuverability and docking options. In this study, we present the first worldwide series of patients undergoing RHM using the new Hugo RAS™ platform. Our objective is to propose optimal operating configuration and setup to fully harness the advantages of the unique modular design of this system.

METHODS

Ten consecutive achalasia patients underwent Robotic Heller's myotomy (RHM) with the Hugo RAS™ system. We prospectively collected patient data, including demographics, comorbidities, ASA class, Eckardt scores, pre-operative manometric data, and EndoFlip parameters. Additionally, we recorded the docking and total operative times.

RESULTS

Between December 2022 and August 2023, 10 patients underwent RHM with the Hugo™ RAS system. Patients had a median age of 42.5 years, 60% were female, and mean BMI was 23.2. Fifty percent had achalasia type 2 and 50% type 1. The median pre-operative integrated relaxation pressure (IRP) was 24.9. Median docking time was 10 min and overall operative time was 129.5 min. All patients, except one with acute coronary syndrome, had an uneventful peri-operative course and were discharged on post-operative day 2.

CONCLUSION

The Hugo™ RAS system is well designed for robotic Heller myotomy. The operative and clinical results are similar to the currently used robotic system; however, the modular design of the system has some differences. These translate to better docking angles and maneuverability as well as console surgeon's ergonomics. Further experience is needed to explore the advantages of the system's modular design and function.

Unilateral Pediculectomy and Reduction with Short-Segment Pedicle Screw Fixation for Thoracolumbar Burst Fracture: A Case Series

BACKGROUND

This study aimed to evaluate the efficacy of unilateral pediculectomy and reduction with short-segment pedicle screw fixation for thoracolumbar burst fracture.

METHODS

We retrospectively reviewed patients who underwent a unilateral pediculectomy and reduction with short-segment fixation and interbody fusion for thoracolumbar burst fracture. The unilateral pediculectomy created sufficient space to approach the ventral side of the spinal cord for removing bone fragments and insertion of an interbody cage to correct kyphosis. Lumbar lordosis (LL), pelvic incidence (PI) minus LL, and segmental Cobb angle were measured at 3 time points: preoperatively, postoperatively, and final follow-up. Furthermore, sagittal vertical axis (SVA) was measured to assess global sagittal balance at the final follow-up.

RESULTS

A total of 10 patients, with a mean age of 39.8 ± 21.0, underwent the surgical procedure. All patients had a thoracolumbar injury classification and severity score > 5. The mean follow-up period was 15.8 ± 13.9 months. The mean postoperative LL (46.0 ± 5.8) was significantly higher (P = 0.008) than the preoperative measurement (32.8 ± 8.2). The mean postoperative PI minus LL (2.2 ± 8.4) was not significantly lower (P = 0.051) than preoperative measurement (15.4 ± 12.6). The mean postoperative segmental Cobb angle (11.4 ± 8.4) was significantly higher (P < 0.001) than the preoperative measurement (-11.6 ± 10.9). At the final follow-up, the mean sagittal vertical axiswas 10.0 ± 28.8 mm.

CONCLUSIONS

Unilateral pediculectomy and reduction with short-segment fixation and interbody fusion served as an efficient surgical method for thoracolumbar burst fracture.

A case series of clinical characteristics and prognosis of congenital hepatoblastoma in a single center

INTRODUCTION AND IMPORTANCE

Congenital hepatoblastoma is an exceedingly rare neoplasm, predominantly documented as isolated instances, with contentious aspects surrounding its therapeutic approaches and prognostic implications. This study aims to comprehensively summarize and evaluate the management experience of congenital hepatoblastoma (CHB).

CASE PRESENTATION

This cohort comprised five infants diagnosed with hepatoblastoma, confirmed through pathological examination, and with an onset of symptoms before 28 days of age. They were enrolled between November 2019 and May 2022. The treatment course they underwent has been summarized, and their prognosis has been subject to analysis.

CLINICAL DISCUSSION

Distinguishing congenital hepatoblastoma from other medical conditions is typically necessary. Given the patient's tender age, the approach to treatment demands comprehensive assessment, particularly in cases involving unique tumor locations or substantial tumor sizes. The selection of treatment modalities, encompassing preoperative neoadjuvant chemotherapy and surgical techniques, becomes of paramount importance. Furthermore, determining the treatment's endpoint poses a notable challenge and often necessitates a comprehensive evaluation.

CONCLUSION

For pediatric patients afflicted with CHB, the application of preoperative neoadjuvant chemotherapy mitigates surgical risks, while the incorporation of surgical procedures followed by postoperative chemotherapy significantly enhances the overall prognosis. Additionally, AFP-L3% levels may serve as a valuable adjunctive marker signifying the conclusion of treatment.

Use of a large-bore 088 intracranial access support catheter for delivery of large intracranial devices: case series with the TracStar LDP in 125 cases

BACKGROUND

The delivery of neuroendovascular devices requires a robust proximal access platform. This demand has previously been met with a 6Fr long sheath (8Fr guide) that is placed in the proximal internal carotid artery (ICA) or vertebral artery segments. We share our experience with the first 0.088 inch 8Fr guide catheter designed for direct intracranial access.

METHODS

We retrospectively reviewed a prospectively maintained IRB-approved institutional database of the senior authors to identify all cases where the TracStar Large Distal Platform (LDP) was positioned within the intracranial vasculature, defined as within or distal to the petrous ICA, vertebral artery (V3) segments, or transverse sinus. Technical success was defined as safe placement of the TracStar LDP within or distal to the described distal vessel segments with subsequent complication-free device implantation.

RESULTS

Over the 41-month study period from January 2020 to June 2023, 125 consecutive cases were identified in whom the TracStar LDP was navigated into the intracranial vasculature for triaxial delivery of large devices, 0.027 inch microcatheter and greater, for aneurysm treatment (n=108, 86%), intracranial angioplasty/stenting (n=15, 12%), and venous sinus stenting (n=2, 1.6%). All cases used a direct select catheter technique for initial guide placement (no exchange). Posterior circulation treatments occurred in 14.4% (n=18) of cases. Technical success was achieved in 100% of cases. No vessel dissections occurred in any cases.

CONCLUSION

The TracStar LDP is an 0.088 inch 8Fr guide catheter that can establish direct intracranial access with an acceptable safety profile. This can be achieved in a wide range of neurointerventional cases with a high rate of technical success.

Odontoid Fracture with Accompanying Severe Atlantoaxial Instability in Elderly Patients-Analysis of Treatment, Adverse Events, and Outcome

(1) Background: In elderly patients with type II odontoid fractures, accompanying severe atlantoaxial instability (AAI) is discussed as a marker possibly warranting more aggressive surgical therapy. This study aimed to characterize adverse events as well as the radiological and functional outcomes of surgical vs. conservative therapy in patients with odontoid fracture and AAI. (2) Methods: Patients aged 65 years and older with type II odontoid fracture and AAI treated were included. AAI was assumed if the mean subluxation across both atlantoaxial facet joints in the sagittal plane was greater than 50%. Data on demographics, comorbidities, treatment, adverse events, radiological, and functional outcomes were analyzed. (3) Results: Thirty-nine patients were included. Hospitalization time was significantly shorter in conservatively treated patients compared to patients with ventral or dorsal surgery. Adverse events occurred in 11 patients (28.2%), affecting 10 surgically treated patients (35.7%), and 1 conservatively treated patient (9.1%). Moreover, 25 patients were followed-up (64.1%). One secondary dislocation occurred in the conservative group (11.1%) and three in the surgical group (18.8%). (4) Conclusions: Despite the potential for instability in this injury, conservative treatment does not seem to lead to unfavorable short-term results, less adverse events, and a shorter hospital stay and should thus be considered and discussed with patients as a treatment option, even in the presence of severe AAI.

Case Report: Robotic pylorus-preserving pancreatoduodenectomy for periampullary rhabdomyosarcoma in a 3-year-old patient

Periampullary neoplasm is rare in pediatric patients and has constituted a strict indication for pancreatoduodenectomy (PD), which is a procedure sporadically reported in the literature among children. Robotic PD has been routinely performed for periampullary neoplasm in periampullary neoplasm, but only a few cases in pediatric patients have been reported. Here, we report the case of a 3-year-old patient with periampullary rhabdomyosarcoma treated with robotic pylorus-preserving PD and share our experience with this procedure in pediatric patients. A 3-year-old patient presented with obstructive jaundice and a mass in the pancreatic head revealed by imaging. A laparoscopic biopsy was performed. Jaundice progressed with abdominal pain and elevated alpha-amylase leading to urgent robotic exploration in which a periampullary neoplasm was revealed and pathologically diagnosed as rhabdomyosarcoma by frozen section examination. After pylorus-preserving PD, we performed a conventional jejunal loop following a child reconstruction, including an end-to-end pancreaticojejunostomy, followed by end-to-side hepaticojejunostomy and duodenojejunostomy. Delayed gastric emptying (DGE) presented with increasing drain from the nasogastric tube (NGT) a week after the surgery and improved spontaneously within 10 days. In a 13-month follow-up until the present, our case patient recovered well without potentially fatal complications, such as pancreatic fistula. Robotic PD in pediatric patients was safe and effective without intra- or postoperative complications.

Treatment of deep single RT2 and RT3 antero-mandibular gingival recessions with a combination of surgical techniques: A case series study

OBJECTIVE

To evaluate root coverage (RC) in deep single antero-mandibular RT2 and RT3 gingival recessions (GR) and to investigate the influence of several factors in RC.

MATERIALS AND METHODS

Fifteen single antero-mandibular GR with a minimum depth of 3 mm were consecutively treated with a new one-stage technique (laterally positioned flap with a tunnel access and a connective tissue graft). At baseline and at 12-month follow-up, the percentage of mean root coverage (%MRC), the recession reduction (RecRed), complete root coverage (CRC) and the gain of keratinized tissue width (KTW) were assessed. Descriptive, intergroup comparative and correlation analyses were performed.

RESULTS

At 12 months, a %MRC of 77.29 ± 21.48% with a mean RecRed of 4.10 ± 1.51 mm was achieved. The %MRC was 84.71 ± 21.08% in RT2, and 62.43 ± 14.17% in RT3. The mean gain of KTW was 2.10 ± 0.89 mm, with a mean gain of 2.0 ± 1.03 mm for RT2 and 2.3 ± 0.57 mm for RT3. CRC was observed in six cases, all of them being RT2. A positive association was found between the %MRC and the initial position of the tooth and of both papillae.

CONCLUSIONS

This technique might be a valuable approach for the treatment of deep single antero-mandibular RT2 and RT3 recessions, even in malpositioned teeth.

CLINICAL SIGNIFICANCE

A combination of different surgical techniques could provide greater vascularization to the CTG especially in malpositioned teeth in sextant V with a large avascular area to be covered.

Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Recurrent Glioblastoma and Radiation Necrosis: A Single-Surgeon Case Series

OBJECTIVE

To evaluate long-term clinical outcomes among patients treated with laser interstitial thermal therapy (LITT) for predicted recurrent glioblastoma (rGBM).

METHODS

Patients with rGBM treated by LITT by a single surgeon (2013-2020) were evaluated for progression-free survival (PFS), overall survival (OS), and OS after LITT.

RESULTS

Forty-nine patients (33 men, 16 women; mean [SD] age at diagnosis, 58.7 [12.5] years) were evaluated. Among patients with genetic data, 6 of 34 (18%) had IDH-1 R132 mutations, and 7 of 21 (33%) had MGMT methylation. Patients underwent LITT at a mean (SD) of 23.8 (23.8) months after original diagnosis. Twenty of 49 (40%) had previously undergone stereotactic radiosurgery, 37 (75%) had undergone intensity-modulated radiation therapy, and 49 (100%) had undergone chemotherapy. Patients had undergone a mean of 1.2 (0.7) previous resections before LITT. Mean preoperative enhancing and T2 FLAIR volumes were 13.1 (12.8) cm3 and 35.0 (32.8) cm3, respectively. Intraoperative biopsies confirmed rGBM in 31 patients (63%) and radiation necrosis in 18 patients (37%). Six perioperative complications occurred: 3 (6%) cases of worsening aphasia, 1 (2%) seizure, 1 (2%) epidural hematoma, and 1 (2%) intraparenchymal hemorrhage. For the rGBM group, median PFS was 2.0 (IQR, 4.0) months, median OS was 20.0 (IQR, 29.5) months, and median OS after LITT was 6.0 (IQR, 10.5) months. For the radiation necrosis group, median PFS was 4.0 (IQR, 4.5) months, median OS was 37.0 (IQR, 58.0) months, and median OS after LITT was 8.0 (IQR, 23.5) months.

CONCLUSIONS

In a diverse rGBM cohort, LITT was associated with a short duration of posttreatment PFS.

Natural History and Histopathology of Expanding Cysts and Hematomas After Stereotactic Radiosurgery for Arteriovenous Malformations of the Brain: A Case Series

BACKGROUND

We reviewed the clinical course and histopathologic findings for cases involving the formation of expanding cysts and/or hematomas after gamma knife surgery (GKS) for arteriovenous malformations (AVMs).

METHODS

We report a single-center retrospective review of 18 patients who presented with cyst and/or hematoma expansion after GKS for AVMs between 1993 and 2023. Expanding cysts and hematomas were defined as well-demarcated cavities filled with fluid or well-marginated heterogenous hematomas presenting with expansion proximal to or in the location of the original AVM, respectively. Patient demographics, AVM characteristics, history of interventions and surgeries, and imaging and histopathologic features of expanding cysts and hematomas were collected for analysis.

RESULTS

Among 1072 AVM patients treated using GKS, 18 presented with expanding cysts or hematomas during a total follow-up period of 16,757 patient-years (0.11 case/100 persons/patient-year). The time to cyst or hematoma identification was 4-13 years after initial GKS, with a mean duration of 8.6 years. Among the patients examined, 7 (38.9%) presented mainly with hematoma, 10 (55.6%) presented mainly with cysts, and 1 presented with approximately equal components of both. Among the 18 patients, 13 (72.2%) underwent craniotomy to treat cyst or hematoma expansion. All the specimens had similar histopathologic characteristics, including organizing hematoma with fresh and old hemorrhage, fibrinoid necrosis of the vessels, gliosis of normal brain tissue, infiltration of hemosiderin-laden histiocytes, and extravascular protein leakage.

CONCLUSIONS

Our findings suggest that the formation of these 2 complications can be attributed to a common mechanism involving radiation-induced vascular damage in brain tissue adjacent to the AVM and subsequent chronic inflammation and capillary dilatation.