Medium-Term Outcomes from a Series of 1000 One Anastomosis Gastric Bypass in Australia: A Case Series

PURPOSE

This study presents the short- (less than 6 months) and medium-term (6 months to 2 years) outcomes for weight loss and type 2 diabetes mellitus (T2DM) for all patients undergoing one anastomosis gastric bypass (OAGB) across multiple institutions between 2015 and 2021.

MATERIALS AND METHODS

A retrospective analysis of prospectively collected databases was performed including 1022 participants who underwent OAGB at multiple institutions by multiple surgeons between 2015 and 2021. Primary outcome was percentage total weight loss (TWL) and secondary outcomes were achieving resolution of T2DM; OAGB specific short- and medium-term complications including bile reflux, marginal ulceration and internal herniation.

RESULTS

One thousand and twenty-two patients underwent OAGB (81% primary surgery). A percentage of 34.1% (n = 349) had a preoperative diagnosis of type 2 diabetes mellitus (T2DM). Mean TWL was 33.6 ± 9%  with a T2DM remission rate of 74% at 1-year post-op. Rates of bile reflux and marginal ulceration was 1.1% (n = 11) and 1.1% (n = 11). There were no cases of internal herniation during the follow-up period.

CONCLUSION

OAGB results has echoed previously published work as being efficacious and safe in a short-medium term. The prevalence of complications, especially bile reflux is overall low in our population and no current evidence exists to support an increased risk of metaplasia or malignancy related to bile within the stomach.

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.

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.

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.

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.

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.

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.

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.

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.

Completely Minimally Invasive Implant Removal and Transforaminal Lumbar Interbody Fusion for Adjacent Segment Disease: Case Series and Operative Video

BACKGROUND AND OBJECTIVES

Adjacent segment disease is a relatively common late complication after lumbar fusion. If symptomatic, certain patients require fusion of the degenerated adjacent segment. Currently, there are no posterior completely minimally invasive techniques described for fusion of the adjacent segment above or below a previous fusion. We describe here a novel minimally invasive technique for both implant removal (MIS-IR) and adjacent level transforaminal lumbar interbody fusion (MIS-TLIF) for lumbar stenosis.

METHODS

Demographic, surgical, and radiographic outcome data were collected for patients with lumbar stenosis and previous lumbar fusion, who were treated with MIS-IR and MIS-TLIF through the same incision. Radiographic outcomes were assessed postoperatively and complications were assessed at the primary end point of 3 months.

RESULTS

A total of 14 patients (7 female and 7 male), with average age 64.6 years (SD 13.4), were included in this case series. Nine patients had single-level MIS-IR with single-level MIS-TLIF. Three patients had 2-level MIS-IR with single-level MIS-TLIF. Two patients had single-level MIS-IR with 2-level MIS-TLIF. Only 1 patient had a postoperative complication-hematoma requiring same-day evacuation. There were no other complications at the primary end point and no fusion failure at the hardware removal levels to date (average follow-up, 11 months). Average increases in posterior disk height and foraminal height after MIS-TLIF were 4.44, and 2.18 mm, respectively.

CONCLUSION

Minimally invasive spinal IR can be successfully completed along with adjacent level TLIF through the same incisions, via an all-posterior approach.

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.

Transpalpebral/Blepharoplasty Incision and Supraorbital Craniotomy for the Treatment of Ethmoidal Dural Arteriovenous Fistulas: A Case Series

BACKGROUND AND OBJECTIVES

Inherent complex angioarchitecture associated with ethmoidal dural arteriovenous fistulas (dAVFs) can make endovascular treatment methods challenging. Many surgical approaches are accompanied by unfavorable cosmetic results such as facial scarring. Blepharoplasty incision of the eyelid offers a minimal, well-hidden scar compared with other incision sites while offering the surgeon optimal visualization of pathogenic structures. This case series aims to report an initial assessment of the safety and efficacy of supraorbital craniotomy by blepharoplasty transpalpebral (eyelid) incision for surgical disconnection of ethmoidal dAVFs.

METHODS

Retrospective chart review was conducted for all patients who underwent blepharoplasty incision and craniotomy for disconnection of ethmoidal dAVFs at our institution between October 2011 and February 2023. Patient charts and follow-up imaging were reviewed to report clinical and angiographic outcomes as well as periprocedural and follow-up complications.

RESULTS

Complete obliteration and disconnection of ethmoidal dAVF was achieved in all 6 (100%) patients as confirmed by intraoperative angiogram with no resulting morbidity or mortality. Periprocedural complications included one case of transient nasal cerebrospinal fluid leak that was self-limiting and resolved before discharge without intervention.

CONCLUSION

Surgical treatment for ethmoidal dAVFs, specifically by transpalpebral incision and supraorbital craniotomy, is a safe and effective treatment option and affords the surgeon greater access to the floor of the anterior fossa when necessary. In addition, blepharoplasty incision addressed patient concerns for facial scarring compared with other incision sites by creating a more well-hidden, minimal scar in the natural folds of the eyelid for patients with an eyelid crease.

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.

Autogenous, alloplastic, or hybrid for total mandibular reconstruction; is here an optimal path?

For less fit patients, total reconstruction of the mandible (TRM) is an elucidated alternative for severe maxillofacial defects. This study aimed to comprehensively review and analyze the existing evidence, irrespective of the underlying pathologies, to provide a consolidated overview of the current state of TRM. An electronic search was performed on PubMed, Embase, Scopus, and Google Scholar to identify studies reporting TRM without restrictions on patient age, type of pathology underlying the mandibular defect, and study type. Electronic search identified 390 studies; only 21 met the inclusion criteria, documenting 7 (33.3%) autogenous, 6 (28.6%) alloplastic, and 8 (38.1%) hybrid TRMs. All studies reported one clinical case, except for two studies that reported two patients treated with TRM. The mean age of the patients was 39.0 ± 19.4 years, and the mean follow-up was 22.3 ± 14.7 months. Osteomyelitis was the most common pathology. Bilateral condyles were preserved in only two cases. The TRM has been reported in clinical cases only and no large cohort study is available. Functional and aesthetic parameters have either not been reported or have been reported in heterogeneous formats, thus hampering comparisons of autogenous, alloplastic, and hybrid TRMs. Overall, TRM in patients presenting with severe maxillofacial defects achieved promising clinical outcomes endowed with acceptable function and aesthetics. Large cohort studies are needed to validate these results.

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.

Alleviation of cadmium toxicity in pea (Pisum sativum L.) through Zn-Lys supplementation and its effects on growth and antioxidant defense

Cadmium significantly impacts plant growth and productivity by disrupting physiological, biochemical, and oxidative defenses, leading to severe damage. The application of Zn-Lys improves plant growth while reducing the stress caused by heavy metals on plants. By focusing on cadmium stress and potential of Zn-Lys on pea, we conducted a pot-based study, organized under completely randomized block design CRD-factorial at the Botanical Garden of Government College University, Faisalabad. Both pea cultivars were grown in several concentrations of cadmium @ 0, 50 and 100 μM, and Zn-Lys were exogenously applied @ 0 mg/L and 10 mg/L with three replicates for each treatment. Cd-toxicity potentially reduces plant growth, chlorophyll contents, osmoprotectants, and anthocyanin content; however, an increase in MDA, H2O2 initiation, enzymatic antioxidant activities as well as phenolic, flavonoid, proline was observed. Remarkably, exogenously applied Zn-Lys significantly enhanced the plant growth, biomass, photosynthetic attributes, osmoprotectants, and anthocyanin contents, while further increase in enzymatic antioxidant activities, total phenolic, flavonoid, and proline contents were noticed. However, application of Zn-Lys instigated a remarkable decrease in levels of MDA and H2O2. It can be suggested with recommendation to check the potential of Zn-Lys on plants under cadmium-based toxic soil.

Right ventricular infarction: epidemiological, clinical, and angiographic characteristics and the outcomes through the experience of a Moroccan cardiology department

Background

Acute myocardial infarction (MI) is a major cause of cardiovascular mortality, which is the leading cause of death in the world. Our objective in this study was to evaluate the epidemiological, clinical, and angiographic features of right ventricular infarction (RVI), as well as its complications and its therapeutic approaches.

Patients and methods

It is a single-centered retrospective descriptive study conducted over a period of 2 years from November 2018 to October 2020. The authors included 82 patients with RVI hospitalized in the cardiovascular ICU during the initial phase of acute coronary syndrome with persistent ST segment elevation. Patients who were diagnosed with RVI at electrocardiogram and echocardiography were recruited.

Results

The authors included 500 patients hospitalized for STEMI, 82 had MI extended to the RV, reflecting a rate of 16.4%. The mean age in our study was 64±12.3 years. Dyslipidemia, diabetes mellitus, and hypertension were the most common cardiovascular risk factors among these patients. RVI co-existed with inferior MI in 62.2 of cases and in 37.8% of anterior MI, while isolated RVI was seen in only one patient. Transthoracic echocardiography showed right ventricular (RV) systolic dysfunction in 24.39% of cases, while RV dilatation was seen in only 10.9% of patients. Therapeutic approach was based essentially on revascularization with thrombolysis and coronary angiography +/- PCI. The percentage of mortality was 2.4%.

Conclusion

RVI is relatively rare and is mostly related to an extension of an inferior MI. Early diagnosis, prompt treatment, and appropriate are the keys to improve prognosis, and reduce complications.

Spinal Cord Stimulation Paddle-to-Percutaneous Revision: Case Series and Technical Description

OBJECTIVE

Spinal cord stimulators (SCSs) can be implanted via a percutaneous or paddle approach, the latter technique requiring a laminotomy or laminectomy. Revision surgery may be necessary in instances of migrated, misplaced, or failed stimulators. When revision of a percutaneous system is necessary, it is common to replace the electrodes with a paddle SCS. This study aims to describe a case series of patients with failed paddle SCS electrodes who underwent revision with percutaneous SCS hardware.

METHODS

A series of 5 patients were retrospectively analyzed. Medical records were reviewed for demographic data, operative technique, postoperative follow-up, and complications.

RESULTS

Five patients were included in this series. The median age was 63 (range 51-84), and the median duration from initial implantation to revision surgery was 19 months (range 5-60). The median operative duration was 92 minutes (mean 99 ± 19.6 minutes). The median length of follow-up after surgery was 24 months (mean 21.8 ± 6.0 months). All patients had improved pain relief and therapeutic coverage with no complications.

CONCLUSIONS

Paddle-to-percutaneous SCS surgery is a feasible and durable revision option in appropriately selected patients.

Ultra-Early (<5 Hours) Decompression for Thoracolumbar Spinal Cord Injury: A Case Series

Early surgical decompression within 24 hours for traumatic spinal cord injury (SCI) is associated with improved neurological recovery. However, the ideal timing of decompression is still up for debate. The objective of this study was to utilize our retrospective single-institution series of ultra-early (<5 hours) decompression to determine if ultra-early decompression led to improved neurological outcomes and was a feasible target over previously defined early decompression targets. Retrospective data on patients with SCI who underwent ultra-early (<5 hours) decompression at a level one metropolitan trauma center were extracted and collected from 2015-2018. American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement was the primary outcome, with ASIA Motor score improvement and complication rate as secondary outcomes. Four individuals met the criteria for inclusion in this case series. All four suffered thoracolumbar SCI. All patients improved neurologically by AIS grade, and there were no complications directly related to ultra-early surgery. Given the small sample size, there was no statistically significant difference in outcomes compared to a control group who underwent early (5-24 hour) decompression in the same period. Ultra-early decompression is a feasible and safe target for thoracolumbar SCI and may lead to improved neurological outcomes without increased risk of complications. This case series can help create the foundation for future, larger studies that may definitively show the benefit of ultra-early decompression.

Clinical characteristics and anaesthetic management of severe scoliosis patients with spinal muscular atrophy: case series

Introduction and importance

There is no expert consensus or guidance on perioperative anaesthesia management for spinal surgery of spinal muscular atrophy (SMA) patients with severe scoliosis (Cobb≧90°). We provide a comprehensive summary of the perioperative characteristics observed in patients with SMA and propose an optimized perioperative management strategy for anaesthesia.

Methods

This study is a retrospective single-centre research. Twenty-six SMA patients with severe scoliosis underwent posterior spinal fusion surgery from September 2019 to September 2022 were enroled. The main outcomes were to show the patients' characteristics in anaesthesia, intra- and post-operative periods.

Outcomes

Nineteen patients underwent awake transnasal/transairway intubation. The median anaesthesia time of 25 patients treated under total intravenous anaesthesia was 425 min. After operation, the Cobb angle and correction rate in the coronal plane were median 54.0° and 54.4%. The length of mechanical ventilation with endotracheal intubation in ICU was median 17.5 h in 8 patients. The ICU length of stay of postoperative hospital was median 19 days. Postoperative pneumonia developed in nine patients, atelectasis in two patients, and pleural effusion in six patients. All patients did not need special oxygen therapy after discharge.

Conclusion

Multidisciplinary consultation, lung-protective ventilation strategy, appropriate anaesthetic drugs and reasonable blood transfusion scheme and postoperative monitoring were important in anaesthesia, intraoperative and postoperative periods in the patients of severe scoliosis with spinal muscular atrophy.

Minimally Invasive Techniques in the Surgical Management of Traumatic Pediatric Thoracolumbar Fractures

BACKGROUND

Thoracolumbar (TL) fractures are uncommon in children. While surgical treatment is recommended for unstable TL fractures, there is no consensus on appropriate surgical treatment. We present a case series of pediatric patients with traumatic TL fractures treated with minimally invasive techniques. We discuss our early experience and technical challenges with navigation and robotic-assisted fixation.

METHODS

A retrospective review of a prospectively maintained trauma database from February 2018 to February 2023 of all pediatric patients (<18 years old) undergoing percutaneous fixation for unstable TL fractures was performed. Minimally invasive techniques included fluoroscopy and/or navigation-guided or robotic-assisted surgery. Clinical course, radiographic findings, and technical challenges were reviewed.

RESULTS

A cohort of 12 patients (age range, 4-17 years) with 6 (50%) Chance fractures, 2 (16%) pars fractures, 2 (16%) pedicle fracture, 1 (8%) burst fracture, and 1 (8%) other fracture were identified. Nine patients had fractures involving the lumbar spine, and the remaining 3 had thoracic fractures. In all cases, percutaneous pedicle screws were placed above and below the fracture with the use of neuronavigation or robotic-assisted navigation (n = 2). Blood loss was <30 mL for single-level fractures and instrumented fusion. Two patients had hardware-related complications. At follow-up (mean 9.67 months after surgery), patients were doing well clinically, and most imaging showed stable alignment.

CONCLUSIONS

Our early experience shows that short segment instrumentation through a minimally invasive approach is a safe and effective surgical option for young pediatric patients with good clinical outcomes and favorable radiographic postoperative finding.

Surgical Management of Craniospinal Axis Solitary Fibrous Tumors: A Single-Institution Case Series and Comprehensive Review of the Literature

BACKGROUND AND OBJECTIVES

Meningeal solitary fibrous tumors (SFTs) comprise 0.4% of primary central nervous system neoplasms and carry metastatic potential. Disease course and optimal management are largely unknown, and there is currently no literature rigorously describing neurological outcomes in surgically managed SFTs. We present one of the largest craniospinal SFT series, analyze patient outcomes, and extensively review the associated literature.

METHODS

All surgically managed SFTs at our institution between January 2005 and March 2023 were retrospectively reviewed. Patient demographics, tumor and radiographic features, treatment, and clinical outcomes were collected. Neurological function was quantified using Frankel grade and Neurologic Assessment in Neuro-Oncology scores. Descriptive statistics, multivariate analysis, log-rank test, and Kaplan-Meier survival analysis were performed.

RESULTS

Twenty-one patients satisfied inclusion criteria. Tumor locations included 15 supratentorial, three infratentorial, and three spinal. All patients underwent surgical resection, and 16 (76.2%) underwent radiation. Six (28.6%) patients had tumor recurrence, and three (14.3%) developed metastasis. Younger age and higher postoperative Frankel grade were significantly associated with increased overall survival (OS) ( P = .011, P = .002, respectively). All patients symptomatically improved or stabilized after surgery, and Neurologic Assessment in Neuro-Oncology score ( P = .001) and functional status significantly improved postoperatively (Karnofsky Performance Status: 65.2 ± 25.2 vs 91.4 ± 13.5, P = .001). Sex, adjuvant radiation, and extent of resection were not significantly associated with OS.

CONCLUSION

SFT of the central nervous system is a rare entity with a variable clinical course. Surgical resection was associated with improved postoperative functional and neurological status. Higher postoperative neurological function was significantly associated with OS. Further studies are warranted to validate a standardized treatment algorithm and investigate the efficacy of adjuvant radiation in SFT.

Experience Using Gentian Violet-Free Dyes for Tissue Visualization

BACKGROUND

 Gentian violet ink is used as a skin marker in various surgical procedures, including neurosurgery. The dye is also used to visualize the edges of blood vessels during bypass surgery. However, gentian violet ink carries the risks of carcinogenicity and venous injury, which causes microvascular thrombosis. In this study, we compare the gentian violet-free dye C.I. Basic Violet 4 (BV4) and gentian violet. The usefulness, in terms of color, and formation of microvascular thrombosis in anastomosis were compared.

METHODS

 We used the gentian violet-free dye in 20 cases involving 3 vascular anastomoses. The bone cutting lines on the bone surface, superior temporal artery, and middle cerebral artery were drawn using BV4 and gentian violet ink.

RESULTS

 The colors of BV4 and gentian violet ink were similar. No thrombus formation was observed at the vascular anastomosis when using BV4.

CONCLUSION

 BV4 can be used similarly to gentian violet ink. No adverse effects such as thrombus formation in microvascular anastomosis were experienced when BV4 was used.

Repeat Flow Diversion for Retreatment of Incompletely Occluded Large Complex Symptomatic Cerebral Aneurysms: A Retrospective Case Series

BACKGROUND AND OBJECTIVES

Data regarding radiographic occlusion rates after repeat flow diversion after initial placement of a flow diverter (FD) in large intracranial aneurysms are limited. We report clinical and angiographic outcomes on 7 patients who required retreatment with overlapping FDs after initial flow diversion for large intracranial aneurysms.

METHODS

We performed a retrospective review of a prospectively maintained database of cerebrovascular procedures performed at our institution from 2017 to 2021. We identified patients who underwent retreatment with overlapping FDs for large (>10 mm) cerebral aneurysms after initial flow diversion. At last angiographic follow-up, occlusion grade was evaluated using the O'Kelly-Marotta (OKM) grading scale.

RESULTS

Seven patients (median age 57 years) with cerebral aneurysms requiring retreatment were identified. The most common aneurysm location was the ophthalmic internal carotid artery (n = 3) and basilar trunk (n = 3). There were 4 fusiform and 3 saccular aneurysms. The median aneurysm width was 18 mm; the median neck size for saccular aneurysms was 7 mm; and the median dome-to-neck ratio was 2.8. The median time to retreatment was 9 months, usually due to symptomatic mass effect. After retreatment, the median clinical follow-up was 36 months, MRI/magnetic resonance angiography follow-up was 15 months, and digital subtraction angiography follow-up was 14 months. Aneurysm occlusion at last angiographic follow-up was graded as OKM A (total filling, n = 1), B (subtotal filling, n = 2), C (early neck remnant, n = 3), and D (no filling, n = 0). All patients with symptomatic improvement were OKM C, whereas patients with worsened symptom burden were OKM A or B. Two patients required further open surgical management for definitive management of the aneurysm remnant.

CONCLUSION

Although most patients demonstrated a decrease in aneurysm remnant size, many had high-grade persistent filling (OKM grades A or B) in this subset of mostly large fusiform aneurysms. Larger studies with longer follow-up are warranted to optimize treatment strategies for atypical aneurysm remnants after repeat flow diversion.

Supinator to Posterior Interosseous Nerve Transfer for Recovery of Hand Opening in the Tetraplegic Patient: A Case Series

BACKGROUND AND OBJECTIVES

Cervical spinal cord injury results in devastating loss of function. Nerve transfers can restore functional use of the hand, the highest priority function in this population to gain independence. Transfer of radial nerve branches innervating the supinator to the posterior interosseous nerve (SUP-PIN) has become a primary intervention for the recovery of hand opening, but few outcome reports exist to date. We report single-surgeon outcomes for this procedure.

METHODS

The SUP-PIN transfer was performed on adults with traumatic spinal cord injury resulting in hand paralysis. Outcome measures include Medical Research Council strength grade for extension of each digit, and angles representing critical apertures: the first web space opening of the thumb, and metacarpophalangeal angle of the remaining fingers. Factors affecting these measurements, including preserved tone and spasticity of related muscles, were also assessed.

RESULTS

Twenty-three adult patients with a C5-7 motor level underwent SUP-PIN transfers on 36 limbs (median age 31 years, interquartile range [21.5, 41]). The median interval from injury to surgery was 10.5 (8.2, 6.5) months, with 9 (7.5, 11) months for the acute injuries and 50 (32, 66) months for the chronic (>18 months) injuries. Outcomes were observed at a mean follow-up of 22 (14, 32.5) months. 30 (83.3%) hands recovered at least antigravity extension of the thumb and 34 (94.4%) demonstrated successful antigravity strength for the finger extensors, providing adequate opening for a functional grasp. Chronic patients (>18 months after injury) showed similar outcomes to those who had earlier surgery. Supination remained strong (at least M4) in all but a single patient and no complications were observed.

CONCLUSION

SUP-PIN is a reliable procedure for recovery of finger extension. Chronic patients remain good candidates, provided innervation of target muscles is preserved. Higher C5 injuries were more likely to have poor outcomes.

Megaprosthetic replacement in complex distal humerus fractures in elderly patients: a case series

BACKGROUND

Managing distal humeral fractures can be challenging for orthopedic surgeons. There are several treatment options for managing this type of fracture, and the treatment method for these fractures should be based on patient-related factors. In elderly patients with osteoporotic bone and severe comminution of the fracture, adequate fixation can be a major challenge for surgeons. The use of megaprosthesis has been recently proposed in traumatology as an alternative to osteosynthesis or conventional prosthesis for the management of comminuted articular fractures in elderly patients with poor bone stock.

METHODS

A consecutive case series of 5 patients who underwent reconstruction of the elbow joint with a trabecular hinged modular elbow megaprosthesis was reviewed retrospectively. All patients included had AO/OTA 13C2 and 13C3 fractures with metaphyseal extension and considerable bone loss of the distal humerus. The primary outcome was the evaluation of functional and clinical outcomes with the MEPS score in comminuted distal humerus fractures with metaphyseal extension and poor bone stock in elderly patients treated with elbow megaprosthesis. The secondary outcome was assessing the treatment-related complication rate of this technique in non-oncological fields.

RESULTS

Five patients were included in the study with a mean age of 82.66 ± 7.72 years at surgery. The mean MEPS value was 63 ± 24.2 at 1 month, 81 ± 23.53 at 3 months, 83 ± 24.2 at 6 months, and 84 ± 24.57 at 12 months. No intraoperative complications were recorded in our series. Of 5 patients, four patients had excellent clinical and functional outcomes. We did not encounter wound dehiscence, prosthetic joint infection, aseptic loosening, or periprosthetic fractures.

CONCLUSIONS

The indication for this type of treatment must be selected and narrowed down, as it is a salvage procedure, and any failure would cause even more complex situations. Short operating times and early mobilization of the elbow are the advantages of this technique.

Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using the LiquoGuard®

OBJECTIVE

Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks.

METHODS

This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure.

RESULTS

Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection.

CONCLUSIONS

Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.

Evaluation of diode laser efficacy in treating benign oral soft tissue masses: A case series

INTRODUCTION AND IMPORTANCE

The diode laser, with a wavelength ranging from 810 to 980 nm, is a modern treatment modality that offers significant advantages in the management of benign oral soft tissue masses. Therefore, this report aimed to assess the efficacy of diode laser application for excisional biopsy of such masses.

CASE PRESENTATION

Three female patients, aged 9, 39, and 45 years, visited the Oral Medicine Clinic with complaints of painless masses in the oral cavity persisting for two to three months. Their intraoral examination showed the presence of pedunculated or sessile exophytic lesions with a smooth surface. The lesions appeared as single, pink to red protrusions located in various sites, including the left buccal mucosa, right lateral border of the tongue, and lower gingiva.

CLINICAL DISCUSSION

Excisional biopsy of the masses was carried out in the patients using the diode laser. The surgical procedures ranged from 10 to 20 min, with minimal intraoperative bleeding and precise cutting, while no pain was reported. Postoperatively, at two weeks and four months follow-up, the intraoral wounds exhibited excellent healing without complications such as pain, bleeding, swelling, scarring, infection, or mass recurrence. The clinical diagnosis of irritational fibroma (two cases) and fibrous epulis were confirmed by histopathological examination.

CONCLUSION

Diode laser emerges as a highly efficacious method for the excisional biopsy of benign oral soft tissue masses, providing intraoperative and postoperative advantages over scalpel surgery.

Graves' disease with only unilateral involvement; a case report

INTRODUCTION

Graves' disease characteristically presents with a diffuse goiter secondary to the autoantibodies that target the thyrotropin receptors of the thyroid gland. Few cases have been reported of only one of the two lobes being affected. The cause of this phenomenon is still uncertain. Here we report on another case of unilateral Graves' disease.

CASE PRESENTATION

A 43-year-old female patient presented with a history of weight loss, palpitations and right sided neck swelling for 4 months. Clinical examination showed an enlarged right thyroid lobe. Laboratory investigations yielded evidence of thyrotoxicosis with suppressed thyroid stimulating hormone. In addition, anti-TSH receptor and anti-thyroperoxidase antibodies were positive. Neck Ultrasound showed an enlarged right thyroid lobe with increased vascularization. The isthmus and left lobe were both normal in size. A Tc99m pertechnetate thyroid scan demonstrated enlargement of the right thyroid lobe with diffuse intense uptake, whereas the left lobe was suppressed. A diagnosis of unilateral Graves' disease was made. The thyrotoxicosis was treated and maintained with methimazole.

DISCUSSION

Unilateral Graves' disease is a rare manifestation of Graves' disease, sharing the same autoimmune background and the symptoms of thyrotoxicosis. Enlargement of only one lobe was evident on clinical examination. The distinctive feature was unilateral uptake during thyroid scintigraphy. The exact pathophysiology of this condition has yet to be elucidated. Management options and responses are similar to those of classical Graves' disease.

CONCLUSION

Unilateral uptake during thyroid scintigraphy and/or unilateral lobar goiter in the setting of hyperthyroidism can be the presentation of unilateral Graves' disease.

Delayed Presenting Gastric Duplication Cyst Mimicking a Left Adrenal Cyst in a Young Female: A Case Report with a Literature Review

Introduction

Gastric duplication cyst (GDC) is a rare congenital anomaly of the gastrointestinal tract. Though GDC is often misdiagnosed, misidentification as an adrenal cyst has rarely been reported. Herein, we report a case of GDC in a young female mimicking an adrenal cyst.

Case Presentation

A 17-year-old female presented with chronic epigastric pain, nausea, and intermittent vomiting. Physical examinations revealed mild tenderness in the epigastric region. Esophagogastroduodenoscopy showed no abnormality. Ultrasound, contrast-enhanced computed tomography scan, and MRI of the abdomen and pelvis showed an oval-shaped left adrenal cystic lesion measuring 33 × 26 mm. Preoperative blood investigations and hormonal assessments were normal. Laparoscopy showed that the cyst originated from the greater curvature of the stomach. The left adrenal gland was normal. After an intraoperative consultation with a gastrointestinal surgeon, a wedge resection of the cyst was performed. Histopathology confirmed the gastric duplication cyst.

Conclusion

GDCs are rare congenital malformations that may become symptomatic during adulthood. They can mimic adrenal cysts and lead to misdiagnosis.

Significant tumor compression of the middle cerebellar peduncle is associated with worse facial nerve outcomes and lower extent of resection in surgery for medium-sized vestibular schwannomas - A radiographic analysis of a case series

BACKGROUND AND OBJECTIVE

Optimizing the extent of resection (EOR) and facial nerve outcomes (FNO) remain a challenge in medium to large vestibular schwannomas (VS). Currently, tumor size has been the only consistently reported factor predicting FNO and EOR. Here, we sought to evaluate whether the degree of the tumor's compression on the middle cerebellar peduncle (PC) influences FNO and EOR in medium to large VS.

METHODS

This retrospective case series included 99 patients who underwent surgical resection of their VSs from 2014 to 2022. Preoperative MR imaging was used to measure the degree of PC. Patient medical records were queried to determine the EOR and FNO.

RESULTS

Patients with unfavorable FNO (HB 3 +) immediately post-op had significantly greater PC than those with favorable FNO (19.9 vs. 15.4 mm, P = .047). This significance was not observed at the last follow-up but there was a trend. When medium-sized tumors (15-30 mm) were analyzed separately, patients with unfavorable FNO immediate post-op and at last follow-up had significantly greater PC than their favorable counterparts (14.1 vs 8.7 mm). Significantly greater PC was also observed in patients who underwent subtotal resection (20.7 mm) compared to near (14.3 mm) and gross total resection (10.8 mm). Multivariate analyses confirmed these findings in medium-sized tumors, but not large-sized tumors.

CONCLUSION

The degree of PC as measured on preoperative imaging can predict FNO and EOR in medium-sized vestibular schwannomas. Medium-sized tumors with > 15 mm of PC likely will have worse FNO and lower EOR.

Longitudinally extensive transverse myelitis, a disabling disorder with a good prognosis: a case series from Nepal

Introduction

Longitudinally extensive transverse myelitis (LETM) is a rare spinal cord disorder with variable etiologies and presentations. It can present solely or as an association with other neurological disorders.

Methodology

It was a series of cases of LETM in a tertiary care hospital.

Clinical presentation and outcomes

The initial three cases presented with bilateral lower extremity weakness and were diagnosed as transverse myelitis while, the fourth case, already diagnosed as LETM presented with seizure followed by loss of consciousness. All four cases had a good prognosis to date with continued physiotherapy.

Conclusion

The early diagnosis of the disease helps to guide the optimal management and decide the potential need for physiotherapy.

Tislelizumab with gemcitabine and cisplatin as a neoadjuvant regimen for muscle-invasive bladder cancer: case series

Introduction and importance

The feasibility of combined tislelizumab with gemcitabine and cisplatin as a neoadjuvant regimen for muscle-invasive bladder cancer (MIBC) remains to be investigated.

Case presentation

The neoadjuvant treatment not only shrunk tumours significantly but also lowered their stages from T4bN1M0, T3N0M0, and T3bN0M0 to pT1, pT0 and pTis, respectively. The treatment suppressed tumour cell proliferation and promoted luminal-to-basal transition.

Clinical discussion

MIBC is an aggressive bladder cancer with poor prognosis. All three patients with MIBC benefited greatly from the neoadjuvant regimen (tislelizumab + gemcitabine + cisplatin). It appears that the effect of the treatment is independent of the levels of programmed death-ligand 1 nor the subtype of urothelial bladder cancer.

Conclusion

Combination of tislelizumab with gemcitabine and cisplatin appeared to be a safe and efficacious neoadjuvant therapy for MIBC.

Subtrochanteric fracture of the femur following knee replacement surgery: A case series and review of the literature

INTRODUCTION AND IMPORTANCE

Knee arthroplasties as an effective intervention is primarily performed in patients with primary osteoarthritis and rheumatoid arthritis. Risk of hip fracture may be either decreased or increased in patients with Knee arthroplasties. There is conflicting evidence in this regard. Over the years, some studies have reported the occurrence of hip fractures following this operation as a rare but severe complication. The aim of the present case series was to report diagnosis and treatment of the mentioned five cases.

CASE PRESENTATION

During a period of two years, five patients with a diagnosis of a subtrochanteric fracture and history of total knee arthroplasty who referred to hospital were selected to include in the present case series. CLINICAL DISCUSSION: the presence of RA and treatment with glucocorticoids, a reduction of BMD following knee replacement surgery, and ultimately, an increase in physical activity and movement after the arthroplasty due to the improvement of preoperational pain, may all contribute in a complex manner to the observed outcome of increased fracture risk in the hip following TKA.

CONCLUSION

In summary, special care including using medications to improve BMD should be taken to minimize the risk of such an event.

Risk factors for sepsis and mortality in patients with emphysematous pyelonephritis : a series of 68 cases (case series)

Background

Emphysematous pyelonephritis (EPN) is a rare and severe necrotizing infection of the kidney with a high rate of complications and mortality. Our aim was to investigate risk factors of urosepsis and mortality in case of EPN.

Materials and methods

Between January 2010 and December 2022 the charts of patients diagnosed with EPN were retrospectively reviewed. Patients medical records were collected and data including demographics, BMI, EPN type, the organism causing the infection and biochemical variables were registered. The authors performed an univariate and multivariate logistic regression analysis for sepsis, septic shock, and mortality. Statistical significance was defined as a P-value of <0.05.

Results

Our study included 68 patients (63% females, mean age 58.6 years old). Forty-eight patients (70.6%) had diabetes. Half of the patients (50%) presented with sepsis and 11 patients (16.2%) developed a septic shock. The following factors were associated with sepsis by univariate analysis: diabetes (P=0.01), higher blood sugar on admission (P=0.01), higher leukocytic count (P<0.001), higher lymphocytic count (P<0.001), and lower platelet to leukocytes ratio (P<0.001). Multivariate regression analysis revealed that the main risk factors of urosepsis were the leukocytic (OR: 85.7; 95% CI: 9.177-800.486; P<0.001) and lymphocytic count (OR: 6.65; 95% CI: 1.228-36.050; P=0.028). Neither of the variables was significantly associated with a higher risk of mortality.

Conclusion

Leukocytic and lymphocytic count on admission are independent simple predictors for sepsis in patients with EPN.