PROSPECTIVE, RANDOMIZED CONTROLLED STUDY EVALUATING DOUBLE BALLOON INTERVENTIONAL ENDOSCOPIC PLATFORM FOR COLORECTAL ESD.

BACKGROUNDS & AIMS: Endoscopic submucosal dissection (ESD) can be challenging/time-consuming. A Double Balloon Interventional Platform (DBIP) was designed to assist with navigation, stabilization, traction and device delivery during complex colorectal polypectomy. STUDY AIM: to compare traditional (T-ESD) to DBIP-assisted ESD (DBIP-ESD) in a prospective, randomized trial. METHODS: Patients with colorectal polyps ≥ 2 cm were randomly assigned (1:1) to DBIP-ESD or T-ESD. Primary study endpoint: mean total procedure time difference between groups. Secondary endpoints: intra-procedural time-points, en bloc resection rate, procedure cost, adverse events, and 3-month assessment. A sample size of 200 subjects for ≥ 80% power was calculated. Interim analysis for early study termination was planned at 70% enrolment if primary endpoint was met (p ≤ 0.05). RESULTS: 147 patients were enrolled between February 2019-February 2020. Seven patients dropped out. Interim analysis was performed on 140 patients (71 DBIP-ESD, 69 T-ESD). Demographics, co-morbidities, lesion size/location/classification were similar between groups. Mean procedure time decreased with DBIP (88.6±42.7 min) vs. T-ESD (139.5±83.2 min), [51 minutes, 36.5%, p<0.001], with procedural savings of $760.16 (14%) per patient after DBIP cost. DBIP increased dissection speed by 49.0% (15.1±8.0 vs 7.7±6.6 cm2/hour, p< 0.001). En bloc resection was superior with DBIP (97.2% vs 87.0%, p=0.030). Mean navigation time with DBIP for sutured defect closure decreased by 7.7 minutes (p<0.001). There were no adverse events in the DBIP group. CONCLUSIONS: DBIP decreased total procedure time, improved en bloc resection rate, facilitated sutured defect closure, making DBIP a promising and cost-effective tool to improve colorectal ESD adoption.

Basilar decompression via a far lateral transcondylar approach: technical note.

BACKGROUND: Treatments for symptomatic or unstable basilar invagination (BI) include posterior decompression, distraction/fusion, trans-nasal or trans-oral anterior decompression, and combined techniques, with the need for occipitocervical fusion based on the degree of craniocervical instability. Variations of the far lateral transcondylar approach are described in limited case series for BI, but have not been widely applied. METHODS: A single-institution, retrospective review of consecutive patients undergoing a far lateral transcondylar approach for odontoidectomy (± resection of the inferior clivus) followed by occipitocervical fusion over a 6-year period (1/1/2016 to 12/31/2021) is performed. Detailed technical notes are combined with images from cadaveric dissections and patient surgeries to illustrate our technique using a lateral retroauricular incision. RESULTS: Nine patients were identified (3 males, 6 females; mean age 40.2 ± 19.6 years). All patients had congenital or acquired BI causing neurologic deficits. There were no major neurologic or wound-healing complications. 9/9 patients (100%) experienced improvement in preoperative symptoms. CONCLUSIONS: The far lateral transcondylar approach provides a direct corridor for ventral brainstem decompression in patients with symptomatic BI. A comprehensive knowledge of craniovertebral junction anatomy is critical to the safe performance of this surgery, especially when using a lateral retroauricular incision.

Chronic inferior vena cava filter thrombosis presenting with low back pain and radiculopathy: Treatment with thrombolysis, filter removal, and stenting.

BACKGROUND: Epidural venous congestion secondary to inferior vena cava (IVC) stenosis is a well-documented cause of low back pain and radiculopathy secondary to compressive effects from the epidural veins, decreased tissue perfusion, and resultant ischemia. METHODS: Single patient case report. CASE DESCRIPTION: We report a unique case of a 62-year-old male with low back pain secondary to IVC stenosis from a chronically occluded IVC filter. The patient's pain resolved with endovascular removal of the occluded filter and recanalization of the IVC. CONCLUSION: We demonstrated that by treating the underlying cause of secondary epidural venous engorgement (occluded IVC filter in this case), the patient experienced resolution of back pain and radiculopathy.

A Review of Neuromodulation for Treatment of Complex Regional Pain Syndrome in Pediatric Patients and Novel Use of Dorsal Root Ganglion Stimulation in an Adolescent Patient With 30-Month Follow-Up.

OBJECTIVES: Complex regional pain syndrome (CRPS) is a disorder in which pain and discomfort are out of proportion to the amount of tissue damage. While prevalence is 20.57 per 100,000 adults, it has not been studied in the U.S. pediatric population. Conservative treatment options include pharmacologic, behavioral, and psychological treatment. If these fail, invasive therapies such as sympathetic blocks and neuromodulation may be performed. The ACCURATE study demonstrated efficacy of dorsal root ganglion (DRG) stimulation for the treatment of refractory CRPS, but did not include pediatric patients and there are no reported cases of its use in the pediatric population. We review the use of neuromodulation for CRPS in pediatric patients and present a novel case using DRG stimulation in an adolescent patient. MATERIALS AND METHODS: A literature search was performed for any studies of neuromodulation as treatment of pediatric CRPS. The literature is reviewed and the case of a 17-year-old female with CRPS treated with DRG stimulation is presented. RESULTS: A 15-year-old female developed CRPS type I of the left ankle after a sports injury. She was unable to wear a shoe or venture outside the home due to pain, swelling, and allodynia. Conservative therapies, including medications, physical therapy, and lumbosacral sympathetic plexus blocks, failed. At age 17, she underwent DRG stimulator lead placement targeting the left L4 and L5 nerve roots. Her therapy provided 100% relief of pain within four days of placement and was sustained at 30-month follow-up. CONCLUSIONS: DRG stimulation has been shown to significantly alter the symptomatology in patients with CRPS. This case suggests that DRG stimulation may be as effective for the treatment of refractory CRPS in pediatric patients as in adults.

Minicraniotomy with a subgaleal pocket for the treatment of subdural fluid collections in infants.

OBJECTIVE: Various surgical techniques have been described to treat subdural fluid collections in infants, including transfontanelle aspiration, burr holes, subdural drain, subduroperitoneal shunt, and minicraniotomy. The purpose of this study was to describe a modification of the minicraniotomy technique that avoids the implantation of external drainage catheters and potentially carries a higher success rate. METHODS: In this retrospective study, the authors describe 11 cases involving pediatric patients who underwent parietal minicraniotomies for the evacuation of subdural fluid collections. In contrast to cases previously described in the literature, no patient received a drain; instead, a subgaleal pocket was created such that the fluid could flow from the subdural to the subgaleal space. Preoperative and postoperative data were reviewed, including neurological examination findings, radiological findings, complications, hospital length of stay, and findings on follow-up examinations and imaging. The primary outcome was failure of the treatment strategy, defined as an increase in subdural fluid collection requiring further intervention. RESULTS: Eleven patients (8 boys and 3 girls, median age 4.5 months) underwent the described procedure. Eight of the patients had complete resolution of the subdural collection on follow-up imaging, and 2 had improvement. One patient had a new subdural collection due to a second injury. Only 1 patient underwent aspiration and subsequent surgical repair of a pseudomeningocele after the initial surgery. Notably, no patients required subduroperitoneal shunt placement. CONCLUSIONS: The authors describe a new surgical option for subdural fluid collections in infants that allows for more aggressive evacuation of the subdural fluid and eliminates the need for a drain or shunt placement. Further work with more patients and direct comparison to other alternative therapies is necessary to fully evaluate the efficacy and safety of this new technique.

Identifying the needs of carers in mental health services.

AIM: To assess all carers in the Gloucester Assertive Community Treatment Team and identify their needs. METHOD: Carers were identified using the definition employed in the Notional Service Framework for Mental Health (DH, 1999): they were family or close friends who spent a minimum of 12 hours per week helping/supporting the service user. Paid carers were excluded. A standardised carer's assessment that had been developed as part of the care programme approach (CPA) was used to evaluate the needs of carers. RESULTS: The study highlights the type of support that carers give those who use the mental health services and reveals the impact that this caring has on them. The carers' needs are identified as: someone to talk to; help with cleaning/ironing; help with finances; support to enable them to take a break; plus respite care and accommodation for the service user. CONCLUSION: Carers play an important role in supporting people who are diagnosed with severe mental illness although further research is necessary to consider the benefits of a closer relationship between the carer, service user and mental health professionals.