Minimally invasive treatment of difficult bleeding lesions of the small bowel.

BACKGROUND: Bleeding lesions of the small bowel are often difficult to identify due to the obscure symptomatology. Localizing these lesions requires specific techniques. The Double-balloon enteroscopy (DBE) could be used to precisely localize and mark lesions, so that a minimally invasive surgical treatment could be performed. METHODS: Twenty robot-assisted small bowel procedures are presented using a combination of DBE for localization and robotic resection. RESULTS: There were 10 jejunal resections and 10 ileal resections. Mean age was 58.7 years. Mean operative time was 153.4 minutes, mean blood loss of 46 mL. No conversion-to-open and there were 4 post-operative complications. The 90-day mortality was nil and the median length of stay was 4.1 days. Final pathology was consistent with malignancy in 10 cases. CONCLUSIONS: The combination of double-balloon enteroscopy and robotic technology allows accurate identification and selective treatment of lesions that could be otherwise difficult to treat in a minimally invasive fashion.

Minimally invasive treatment of difficult bleeding lesions of the small bowel.

BACKGROUND: Bleeding Lesions of the small bowel are often difficult to identify due to the obscure symptomatology. Localizing these lesions requires specific techniques. The Double- balloon enteroscopy (DBE) could be used to precisely localize and mark lesions, so that a minimally invasive surgical treatment could be performed. PATIENTS & METHODS: 20 robot-assisted small bowel procedures are presented using a combination of DBE for localization and robotic resection. RESULTS: There were 10 jejunal resections and 10 ileal resections. Mean age was 58.7 years. Mean operative time was 153.4 minutes, mean blood loss of 46 ml. No conversion-to-open and there were 4 post-operative complications. The 90-day mortality was nil and the median LOS was 4.1 days. Final pathology was consistent with malignancy in 10 cases. CONCLUSIONS: The combination of double balloon enteroscopy and robotic technology allows accurate identification and selective treatment of lesions that could be otherwise difficult to treat in a minimally invasive fashion.

Frontolateral pins for halo ring placement: reassessment of a common neurosurgical procedure with CT measurements of skull thickness.

OBJECT: Halo orthosis placement is a common neurosurgical procedure for the treatment of cervical spine injuries. Frontal sinus puncture by the anterior pins may occur using standard techniques, and up to 30% are dissatisfied with forehead scarring, especially women and African Americans. METHODS: The authors describe a frontolateral (FL) anterior pin site placement supported by high-resolution CT scan skull thickness measurements. The standard supraorbital (SO) pin site is several centimeters above the lateral orbit, whereas the FL pin site is 2-3 cm posterolateral to the SO site. Frontolateral placement is just anterior to the temporalis muscle close to a triangular anterior projection of the temporal hairline. For quantitative information on skull thickness at the SO and FT pin sites, thin 0.625-mm CT scan measurements of the outer table, diploic space, and inner table were obtained in 40 adults (80 sites). RESULTS: The mean values for total skull thickness at the SO and FT sites were not significantly different. The inner table was significantly thicker at the FL site in both males and females, buttressed by the nearby greater sphenoid wing. The mean total skull thickness was significantly less in females than in males, but the values were not significantly different at the SO and FL sites. CONCLUSIONS: The FL and SO anterior pin sites are comparable with respect to skull thickness CT measurements, with a significantly thicker inner table at the FL site. In the senior author's experience, the FL anterior pin site yielded secure fixation without skull perforation, neurovascular injury, or propensity to infection. The cosmetic result of the FL site is more acceptable, and the authors recommend its general usage be adopted.

Chronic epilepsy due to low grade temporal lobe tumors and due to hippocampal sclerosis: do they differ in post-surgical outcome?

Chronic seizures as a presenting feature of low grade temporal lobe gliomas and hippocampal sclerosis (HS) are reported to have similar outcomes although the prognostic indicators may not be the same. This study seeks to identify the variables that are associated with poor surgical outcome in both conditions. A retrospective analysis from our epilepsy data base was performed. All low-grade temporal lobe gliomas were selected and relevant variables were compared to the same variables in HS patients. There were 34 tumors (out of 233 cases of chronic temporal lobe epilepsy = 14.6 %) with a mean age of onset of 19 years, and the preoperative duration was 12.3 years. When compared to 120 HS patients both of these factors were significantly different (p < 0.001). Age at the time of surgery for tumors was 31.08 (p = 0.5). Tumors were left sided in 20 patients. In tumor cases amygdala resection was complete in 75 %, for hippocampus 24 % were complete and 39 % partial. Astrocytoma, ganglioglioma and oligodendroglioma constituted 80 % of tumor cases. Good outcome (Engel's Class I) was achieved in 88.2 % of tumor cases and 71 % of HS cases while poor outcome (Class III + IV) was seen in 5.9 and 16.7 % respectively. The follow up period for the two groups was not significantly different. In multivariate logistic regression analysis, the groups differed significantly in preoperative delay (between diagnosis and surgery) and in epilepsy outcome. Chronic temporal lobe epilepsy due to low-grade tumors had significantly better surgical outcome with considerably less preoperative delay. The age of onset of seizures was younger in HS patients but a delay in surgical treatment was significantly longer. Given that the diagnosis of treatment-resistant TLE secondary to HS can be established after two failed AED trials at optimal doses, shortening the interval between diagnosis and surgery may improve epilepsy outcome.

Psychomotor seizures, Penfield, Gibbs, Bailey and the development of anterior temporal lobectomy: a historical vignette.

Psychomotor seizures, referred to as limbic or partial complex seizures, have had an interesting evolution in diagnosis and treatment. Hughlings Jackson was the first to clearly relate the clinical syndrome and likely etiology to lesions in the uncinate region of the medial temporal lobe. With the application of electroencephalography (EEG) to the study of human epilepsy as early as 1934 by Gibbs, Lennox, and Davis in Boston, electrical recordings have significantly advanced the study of epilepsy. In 1937, Gibbs and Lennox proposed the term "psychomotor epilepsy" to describe a characteristic EEG pattern of seizures accompanied by mental, emotional, motor, and autonomic phenomena. Concurrently, typical psychomotor auras and dreamy states were produced by electrical stimulation of medial temporal structures during epilepsy surgery by Penfield in Montreal. In 1937, Jasper joined Penfield, EEG was introduced and negative surgical explorations became less frequent. Nevertheless, Penfield preferred to operate only on space occupying lesions. A milestone in psychomotor seizure diagnosis was in the year 1946 when Gibbs, at the Illinois Neuropsychiatric Institute, Chicago, reported that the patient falling asleep during EEG was a major activator of the psychomotor discharges and electrographic ictal episodes becoming more prominently recorded. Working with Percival Bailey, Gibbs was proactive in applying EEG to define surgical excision of the focus in patients with intractable psychomotor seizures. By early 1950s, the Montreal group began to clearly delineate causative medial temporal lesions such as hippocampal sclerosis and tumors in the production of psychomotor seizures.