Deep brain stimulation in a pediatric dystonia patient with cochlear implants and mitochondrial disorder: novel application of a frameless stereotactic system and navigating the anesthesia choice and neurosurgical complexities. Illustrative case.

BACKGROUND: This report presents a case of medically refractory dystonia in a pediatric patient successfully treated with bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) while under general anesthesia by using microelectrode recordings (MERs) with intraoperative computed tomography (CT). OBSERVATIONS: The patient was an 18-year-old female with primary dystonia secondary to mitochondrial Leigh syndrome. Her past medical history was significant for complex partial epilepsy and hearing loss treated with cochlear implants. Her cochlear implants precluded anatomical targeting via magnetic resonance imaging. Additionally, the patient could not tolerate awake surgery with MER. The decision was made to proceed with bilateral STN DBS with intraoperative CT with the patient under general anesthesia. The patient's cochlear implants made standard frame placement difficult, so navigation was performed with the Nexframe system. Recordings were obtained with the patient under general anesthesia with ketamine, dexmedetomidine, and remifentanil. At the 3- and 6-month follow-ups, the patient demonstrated marked improvement in dystonia without neurological complications. LESSONS: This is the first case of dystonia secondary to Leigh syndrome treated with DBS. Additionally, the authors describe the novel use of the Nexframe for DBS lead placement in a pediatric patient. This demonstrates that STN DBS with the use of MER and intraoperative CT can be a safe and effective method of treating dystonia in certain pediatric patients.

Where are sleeves performed? An analysis of inpatient versus outpatient databases in a large state.

BACKGROUND: The sleeve gastrectomy (SG) is the most common bariatric surgery in the United States today. There is a trend toward performing SG as an outpatient procedure, either in an ambulatory setting or as an outpatient at a larger hospital. The term "outpatient" is used to designate essentially any patient without an inpatient order. Texas maintains the Texas Inpatient Public Use Data File (IPUDF) database and the Texas Outpatient Public Use Data File (OPUDF) database for inpatient and outpatient settings, respectively. OBJECTIVES: To determine where SGs are performed by evaluating the Texas IPUDF and OPUDF for 2016. SETTING: University hospital, United States. METHODS: The Texas IPUDF and OPUDF were searched with the Current Procedural Terminology code of 43775 and the International Classification of Diseases, 10th revision, procedure code of 0DB64Z3. Patient demographic characteristics were also examined. We looked at the top 5 diagnoses in each database. RESULTS: Of the 16,855 SGs performed in Texas in 2016, outpatient SGs accounted for 31.0% (5227 cases), and inpatient SGs accounted for 69% of the total with 11,628 cases reported. For patients reported in the OPUDF, mean length of stay (LOS) was 2.1 (standard deviation 3.2) days with a median of 1.0 (interquartile range = 1, 2) days; for patients in the IPUDF, mean LOS was 1.6 (standard deviation 1.5) days, and the median was 1.0 (interquartile range = 1, 1) days. CONCLUSION: A third of SGs in Texas were performed under outpatient status. Further study is needed to determine the safety of this practice.