Candidates For Surgical Treatment Research Articles

Atlas of the normal intracranial electroencephalogram: neurophysiological awake activity in different cortical areas.

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Providencia stuartii Aortic Prosthetic Valve Endocarditis with Formation of Paravalvular Pseudoaneurysm

Infective endocarditis (IE) is characterized by high morbidity and mortality. Providencia stuartii infections are very rare and mainly acquired in a hospital setting, being isolated primarily in urine cultures of patients with longterm urinary catheters; rarely causing bacteremia and endocarditis. The authors present a case of a 74-year-old male patient with vascular risk factors and a biological aortic prosthetic valve hospitalized for urosepsis with P. stuartii bacteremia. He underwent antibiotic susceptibility-guided therapy, resulting in both negative urine and blood cultures. However, the patient was later re-admitted due to persistent P. stuartii urosepsis and bacteremia. A transesophageal echocardiogram revealed endocarditis of the prosthetic aortic valve, complicated with extensive aortic root pseudoaneurysm, fistulized into the left atrium. Given the co-comorbidities and extent of the disease, he was not a candidate for surgical intervention and therefore maintained broad-spectrum antibiotic therapy. Unfortunately, the patient didn’t respond to best medical treatment and died of septic shock.

Surgical treatment of recalcitrant lateral epicondylitis using a minimal incision technique

BACKGROUND: Lateral epicondylitis responds well to conservative methods of treatment such as drugs, braces and local infiltration of steroids, autologous blood, and platelet-rich plasma. The patients who do not respond to conservative methods become candidates for surgical intervention. In our study, we have performed the Nirschl procedure through a smaller incision. MATERIALS AND METHODS: Our study included 18 patients having lateral epicondylitis treated with an open debridement of extensor carpi radialis brevis using a small incision. In our study, we had six males and 12 females, with 14 patients having involvement on the right side and four patients on the left side. Patients were followed up for a mean period of 28.8 months, and the final outcome was assessed using the QuickDASH score, visual analog scale (VAS), and the Nirschl and Pettrone's grading system. RESULTS: According to the QuickDASH scoring scale, the preoperative mean score improved from 74.4 to 49.7 postoperatively, which is statically significant (P CONCLUSION: Surgical intervention via the Nirschl operative technique is ideal for recalcitrant lateral epicondylitis.

Outcome of surgery for nerve injury following total hip arthroplasty.

During hip replacement, nerves in the operative field can be injured accidently. Additional surgical procedures can help restore function and reduce pain if there has been no recovery. One-hundred sixty-two patients presented with nerve injuries, and 113 were candidates for surgical treatment. The author performed 91 procedures on the injured limb (80 patients; 11 had 2 procedures) consisting of shortening, sympathectomy, tendon transfer, neurolysis or nerve repair/graft and 30 spinal and three fibular-neck decompressions. A meaningful recovery was defined as an increase of >1 level in strength or a reduction of >2 points on the visual analogue (VAS) pain scale. Of 21 shortening procedures, 15 improved; of 12 nerve repair/grafting procedures, four improved. No patient >55years of age made a meaningful recovery from a nerve repair/graft. One obturator nerve was resected and did not improve, and two were buried in muscle and had less pain. Of seven sympathectomies, six had less dysesthetic pain. Of 28 nerves treated with neurolysis, 24 made a meaningful recovery, with 13 making a near complete recovery. Of three fibular decompressions, two recovered completely. Of 20 tendon transfers, 18 made a meaningful recovery. Of 30 spinal decompressions, 25 made a meaningful recovery. There were six (5.3%) surgical complications (2 worsening pain, 2 infections, 2 deformities from tendon transfer). If a sciatic, femoral or obturator nerve injury due to hip replacement does not recover spontaneously, additional surgical procedures can be of benefit.

Presentation and outcomes in surgically and conservatively managed pediatric Rathke cleft cysts.

OBJECTIVE Rathke cleft cysts (RCCs) are sellar lesions that are commonly encountered in adults but infrequently diagnosed in the pediatric population. As a result, the optimal management of pediatric RCCs remains a subject of controversy. Only 2 prior surgical series have been published on pediatric RCCs and no study has compared the presentation and outcomes of surgically versus conservatively managed cases. The authors therefore performed a comparative analysis of pediatric cases of RCC in which patients were treated with surgery or managed in a conservative manner. METHODS All cases involving pediatric patients diagnosed with an RCC at the University of Virginia between 2000 and 2016 were included in this study. Patient medical records, operative notes, and neuroimaging findings were reviewed. Patients who developed visual field deficits, radiographic evidence of chiasmal compression, or medically refractory headaches were considered candidates for surgical intervention. All patients who were selected for surgery underwent an endoscopic endonasal approach with cyst fenestration. RESULTS A total of 24 pediatric patients were diagnosed with an RCC over a 16-year period. Seven patients ultimately underwent transsphenoidal cyst fenestration, and 17 were managed conservatively. The patients' age at diagnosis, cyst size, and pituitary function at the time of RCC diagnosis were similar in the conservatively and surgically managed cohorts. At diagnosis, 19 of 24 patients endorsed headaches that led to neuroimaging. All patients in the surgical cohort endorsed severe headaches at diagnosis compared with 71% in the conservative group. For the 7 patients treated with surgery, complete cyst evacuation was achieved in 86% of cases. Transient postoperative endocrinopathy occurred in 4 (57%) of 7 surgically treated individuals and resolved in all cases. In the conservative cohort, 1 patient developed a delayed pituitary-related endocrinopathy. Headache resolution occurred in 5 (71%) of the 7 patients who underwent surgery and 7 (58%) of the 12 who were treated without surgery. Cyst recurrence was documented in 1 individual in the surgical cohort who underwent a subtotal cyst fenestration that ultimately required re-intervention. In the conservative cohort, spontaneous cyst shrinkage occurred in 35% of patients with a median time to regression of 23.5 months. CONCLUSIONS Pediatric RCCs are benign sellar lesions that often present with headaches. While cyst fenestration mitigates headaches in most patients, the majority of conservatively managed pediatric patients with RCCs will have spontaneous headache resolution. Furthermore, spontaneous RCC regression occurs in a substantial number of individuals. Thus, in the absence of optic compression, visual field deficit, or diagnostic uncertainty, many pediatric cases of RCC can be managed conservatively.

Comparison of postoperative clinical outcome after repairing surgery for lumbar spinal stenosis between diabetic and nondiabetic patients.

Background:Poorer postoperative outcome is suggested after repairing surgery in diabetic patients with lumbar spinal stenosis in comparison with nondiabetic patients. The present study aimed to compare the clinical outcome of surgery for lumbar spinal stenosis and diabetic and nondiabetic patients to highlight the effect of diabetes on prognosis of this surgical procedure.Methods:This prospective cohort study is conducted on 25 diabetic patients with lumbar spinal stenosis who were candidate for surgical treatment. A gender, age, and body mass index-matched group including 30 nondiabetic patients with lumbar spinal stenosis was considered as the control. The clinical condition of the patients was assessed based on oswestry disability index (ODI) before and immediately after surgery.Results:There was no difference in baseline ODI index between diabetes and diabetes group (73.68 ± 18.89 vs. 71.20 ± 18.27, P = 0.625), whereas postprocedure ODI was significantly higher in diabetic patients than in nondiabetic group (54.32 ± 19.03 vs. 29.47 ± 18.75, P < 0.001). The multivariable logistic regression analysis could show a difference in postoperative ODI between diabetic and nondiabetic patients with the presence of baseline variables as the confounders (beta = −24.509, P < 0.001).Conclusion:Lower improvement in physical ability is expected in diabetic patients after surgery for lumbar spinal stenosis when compared to nondiabetes patients.

350 Stereoelectroencephalography for Refractory Localization-related Epilepsy

Abstract INTRODUCTION Patients with pharmacotherapy-resistant localization-related epilepsy (LRE) may be candidates for surgical intervention if the seizure onset zone can be well localized. Long used in Europe, intracranial recording with stereoelectroencephalography (sEEG) is emerging as an alternative to subdural strip and grid techniques in North American centers. METHODS We reviewed our initial experience in a consecutive cohort of patients who underwent sEEG for extraoperative monitoring of LRE between May 2014 and September 2016. RESULTS &gt;Fifty patients (37 adult, 13 pediatric) were implanted with 536 depth electrodes (mean 10.7 per patient, 7.9 per implanted hemisphere). Among 18 patients with suspected lesional epilepsy (including 3 with bilateral and 4 with multiple unilateral lesions), sEEG identified lesional foci in 16 (89%) cases (15 unifocal, 1 bitemporal). Two patients required further localization with subdural grids. Of 20 patients with nonlesional epilepsy, sEEG localized foci in 16 (80%) cases (13 unifocal, 2 bitemporal, 1 multifocal). Two patients had foci near eloquent cortex requiring grid placement for further mapping and two could not be focally localized. Finally, of 12 patients who had previous resections or ablations, sEEG localized foci in 11 (92%) cases (10 peri-cavity, 1 multifocal) and 1 was not focally localized. Complications were minor and rare. In 536 electrodes, there were no (0.0%) infections or symptomatic hemorrhages and 3 (0.6%) small, asymptomatic hemorrhages. One electrode was deflected into the subdural space during placement and 1 patient required replacement of 2 electrodes that were broken during seizures in the monitoring unit. CONCLUSION Robot-assisted sEEG is a safe and useful method for localizing epileptogenic foci in patients with lesional, nonlesional, and previously treated LRE. The success of seizure onset localization and safety compare favorably with invasive subdural monitoring. Longer clinical follow up will be required to determine whether sEEG monitoring improves long-term seizure freedom in these challenging epilepsy patients.

P235 Localizing non-epileptic abnormal brain function in children using high density EEG (HDEEG): Electric source imaging (ESI) of focal slowing

Objectives Interictal focal slowing is an important EEG index of brain activity dysfunction, possibly representing an additional tool for presurgical evaluation in pediatric epilepsy. Here, we investigate the accuracy of electric source imaging (ESI) applied to pathological focal EEG slowing (FS) as new neurophysiological index localizing the epileptic focus in children with drug-resistant epilepsy. Method We selected16 children (12 ± 4yrs), who performed hdEEG, presurgical evaluation and underwent surgical resection with at least 1 year of post-operative seizure freedom. For each patient, we exported 15 FS-epochs of 2 s. The S-transform was applied to select the frequency band (delta/theta: 1–4 Hz/4–8 Hz) with maximal power. ESI was performed using a distributed linear inverse solution and an individual head model. The solution point with maximal average power in the band of interest was selected as the source of focal slowing (ESI-FS). Finally, we computed the Euclidian distance between the ESI-FS and the nearest solution point included in the resection with a 5 mm margin. Results In 11/16 (69%), ESI of focal slowing (ESI-FS) was inside the margins of resection. The remaining 5/16 cases had distances 15 mm. Discussion and Conclusions These findings suggest that a “non-epileptiform” activity, such as focal slowing, could help to localize the epileptogenic zone. ESI-FS may aid presurgical lateralization in patients without focal interictal spikes improving the identification of possible good candidate for surgical treatment. Significance The study provides a new quantitative marker of brain dysfunction in children, with a potential application to other neurological disorders, using a non-invasive tool as hdEEG.

69-Year-Old Man With Abdominal Pain and Obstipation

69-Year-Old Man With Abdominal Pain and Obstipation

The Usefulness of Surgical Treatment in Slow-Flow Vascular Malformation Patients.

BackgroundMany difficulties exist in establishing a treatment plan for slow-flow vascular malformation (SFVM). In particular, little research has been conducted on the surgical treatment of SFVMs. Thus, we investigated what proportion of SFVM patients were candidates for surgical treatment in clinical practice and how useful surgical treatment was in those patients. MethodsThis study included 109 SFVM patients who received care at the authors’ clinic from 2007 to 2015. We classified the patients as operable or non-operable, and analyzed whether the operability and the extent of the excision varied according to the subtype and location of the SFVM. Additionally, we investigated complications and self-assessed satisfaction scores. ResultsOf the 109 SFVM patients, 59 (54%) were operable, while 50 (46%) were nonoperable. Total excision could be performed in 44% of the operable SFVM patients. Lymphatic malformations were frequently non-operable, while capillary malformations were relatively operable (P=0.042). Total excision of venous malformations could generally be performed, while lymphatic malformations and combined vascular malformations generally could only undergo partial excision (P=0.048). Complications occurred in 11% of the SFVM patients who underwent surgery; these were minor complications, except for 1 case. The average overall satisfaction score was 4.19 out of 5. ConclusionsBased on many years of experience, we found that approximately half (54%) of SFVM patients were able to undergo surgery, and around half (44%) of those patients were able to fully recover after a total excision.Among the patients who underwent surgical treatment, high satisfaction was found overall and relatively few complications were reported.

Total Hip Arthroplasty Outcomes: An 18-Year Experience in a Single Center: Is Systemic Lupus Erythematosus a Potential Risk Factor for Adverse Outcomes?

BackgroundIn patients with systemic lupus erythematosus (SLE), persistent joint activity and treatment with glucocorticoids are associated with musculoskeletal complications. About 30% of these patients become candidates for surgical treatment. The aim of this study was to evaluate postoperative outcomes after total hip arthroplasty (THA) in SLE patients. MethodsWe performed a retrospective cohort study at a tertiary care center in Mexico City between 1995 and 2013. All patients with SLE who underwent THA during that period were included (n = 58). They were compared with 2 control groups, one from another inflammatory arthropathy (rheumatoid arthritis, n = 58) and other noninflammatory (osteoarthritis, n = 58), matched by gender and date of surgery. The primary outcome was the frequency of postoperative complications during follow-up. ResultsWe included 174 patients who underwent THA during the study period. Patients with SLE were younger (P < .0001), had a longer hospitalization stay (P = .001), and required more transfusions (P = .004). Global complications in THA in patients with SLE were more prevalent than rheumatoid arthritis (36.2% vs 15.5%, P = .029) and osteoarthritis (36.2% vs 5.1%, P < .0001) patients. After multivariate analysis, risk factors for THA complications were: SLE (hazard ratio 2.8, 95% confidence interval 1.2-6.8; P = .018) and low postoperative hemoglobin (hazard ratio 0.77, 95% confidence interval 0.73-0.83; P < .0001). Long-term complications after THA were similar among groups. ConclusionThis is the largest single-center study regarding clinical outcomes after THA in SLE patients. Our data suggest that SLE is an independent risk factor for adverse postoperative outcomes, mainly immediate complications, but the long-term outcome is good enough to offer surgical treatment that will improve quality of life.

Morphological response contributes to patient selection for rescue liver resection in chemotherapy patients with initially un-resectable colorectal liver metastasis.

Morphological response is considered an improved surrogate to the Response Evaluation Criteria in Solid Tumors (RECIST) model with regard to predicting the prognosis for patients with colorectal liver metastases. However, its use as a decision-making tool for surgical intervention has not been examined. The present study assessed the morphological response in 50 patients who underwent chemotherapy with or without bevacizumab for initially un-resectable colorectal liver metastases. Changes in tumor morphology between heterogeneous with uncertain borders and homogeneous with clear borders were defined as an optimal response (OR). Patients were also assessed as having an incomplete response (IR), and an absence of marked changes was assessed as no response (NR). No significant difference was observed in progression-free survival (PFS) between complete response/partial response (CR/PR) and stable disease/progressive disease (SD/PD), according to RECIST. By contrast, PFS for OR/IR patients was significantly improved compared with that for NR patients (13.2 vs. 8.7 months; P=0.0426). Exclusion of PD enhanced the difference in PFS between OR/IR and NR patients (15.1 vs. 9.3 months; P<0.0001), whereas no difference was observed between CR/PR and SD. The rate of OR and IR in patients treated with bevacizumab was 47.4% (9/19), but only 19.4% (6/31) for patients that were not administered bevacizumab. Comparison of the survival curves between OR/IR and NR patients revealed similar survival rates at 6 months after chemotherapy, but the groups exhibited different survival rates subsequent to this period of time. Patients showing OR/IR within 6 months appeared to be oncologically stable and could be considered as candidates for surgical intervention, including rescue liver resection. Comparing the pathological and morphological features of the tumor with representative optimal response, living tumor cells were revealed to be distributed within the area of vascular reconstruction induced by bevacizumab, resulting in a predictive value for prognosis in the patients treated with bevacizumab. The present findings provided the evidence for physicians to consider patients with previously un-resectable metastatic colorectal cancer as candidates for surgical treatment. Morphological response is a useful decision-making tool for evaluating these patients for rescue liver resection following chemotherapy.

A novel method for treatment of chronic anal fissure: adipose-derived regenerative cells - a pilot study.

The purpose of this study was to investigate the safety and feasibility of autologous adipose-derived regenerative cells (ADRC) in the treatment of chronic anal fissure. A prospective pilot study was conducted in six patients with chronic anal fissures at the First Surgical Clinic, Clinical Center of Serbia and at the BelPrime Clinic, Belgrade, Serbia. All patients were candidates for surgical treatment. The average duration of symptoms was 24months. Pain assessment was quantified using a visual analogue scale and bowel continence was assessed using the Wexner incontinence score. Both were assessed before treatment and during each postoperative outpatient visit. Liposuction was performed under local or general anaesthesia. Extraction of ADRC was achieved with a closed automated medical device. The fat and ADRC were injected subcutaneously into the edge of the fissure. The rest of the pellet was infiltrated into the internal anal sphincter. The study has been registered at ClinicalTrials.gov (NCT02628522). Complete healing of the anal fissure and the disappearance of symptoms was achieved in all patients. The average time to complete pain cessation was 33.7±15.0days. All fissures healed after 3months and remained healed 12months after the procedure. There were no complications related to the procedure. The application of ADRC may be an alternative to lateral sphincterotomy and a reliable procedure which avoids faecal incontinence.

Predictors of Improvement in Storage Symptoms at Three Years After 120W GreenLight High Performance System Laser Treatment for Benign Prostate Hyperplasia.

This study was conducted to investigate the indicators of recovery in storage symptoms after GreenLight High Performance System photoselective vaporization of the prostate (HPS-PVP) in men with benign prostate hyperplasia. A total of 155 men with a baseline subtotal storage symptom score of international prostate symptom score (sIPSS) greater than or equal to six, who underwent HPS-PVP and were followed up on for as much as 3 years, were included in this retrospective study. Surgical outcomes were evaluated at 1, 3, 6, 12, 24, and 36 months after surgery. Improvement of storage symptoms was defined as a reduction greater than or equal to 30% of sIPSS after surgery compared to the baseline. The mean age was 67.5 ± 7.8 years and the preoperative median prostate-specific antigen, mean total prostate volume, and sIPSS were 1.95 (0.97-5.27) ng/mL, 52.1 ± 32.5 mL, and 9.6 ± 2.6, respectively. The mean improvement rate of sIPSS after 3 years was 34.4%. Age was only associated with an improvement of sIPSS in the multivariate analysis (odds ratio = 0.889, p = 0.008). The mean improvement rates of sIPSS according to age group (<65 vs ≥65) were 44.7% and 26.0%, respectively. Age can serve as an independent predictor of storage symptom improvement for as much as 3 years. Therefore, we suggest that older patients who are being considered candidates for surgical treatment should be further evaluated.

Posterior Ankle Impingement Syndrome

Posterior ankle impingement syndrome is commonly seen in athletes whose sport requires them to repetitively plantarflex the ankle such as in ballet dancers, soccer players, and gymnasts. This manifests as activity-related pain that is localized to the posterior ankle. It can be a debilitating condition that limits the athlete׳s ability to perform at the optimal level. Posterior impingement is due to either soft tissue or osseous impingement. The most common causes are synovitis, flexor hallucis longus tendinitis, and symptomatic os trigonum. Nonoperative management typically involves restriction or modification of activities, brief immobilization, injections, and oral anti-inflammatory medications. Patients dissatisfied with the outcomes of nonoperative treatment are candidates for surgical intervention. Surgical intervention traditionally has been an open debridement of the posterior ankle. This approach has been largely replaced by posterior ankle arthroscopy, now the procedure of choice for surgical management of posterior impingement. In comparison to open surgery, posterior ankle arthroscopy results in significant improvements in foot and ankle patient-reported outcome scores, an earlier return to sport, and a lower rate of complications. The most common complication is sural nerve neuropraxia.

Radiofrequency ablation for liver metastases in patients with gastric cancer as an alternative to hepatic resection

BackgroundThe purpose of this retrospective study was to determine whether RFA could provide an alternative treatment modality for selected patients who are not candidates for hepatic resection.MethodsA total of 18 consecutive patients with liver metastases alone from gastric cancer treated with radiofrequency ablation (RFA, n = 11) or hepatic resection (HR, n = 7) at Seoul St. Mary’s Hospital, Korea, between January 2000 and September 2014, were enrolled.ResultsThe median OS and DFS in the RFA group were 40.5 ± 22.3 and 10.3 ± 1.07 months, respectively. There was no significant difference between the RFA and HR groups in terms of baseline characteristics except for performance status. Mean survival and DFS times of all patients were 60.1 ± 9.4 and 40.9 ± 10.2 months, respectively. Mean OS times in the HR and RFA groups were 67.5 ± 15.4 and 51.1 ± 9.8 months (P = 0.671), respectively, and the mean DFS time in the HR group (74.1 ± 14.2 months) was longer than that in the RFA group (26.9 ± 9.2 months), but the difference was not significant (P = 0.076).ConclusionsIn patients who are not candidates for surgical treatment, RFA may be an alternative to HR.

New trends in interventional pulmonology.

As the field of interventional pulmonology continues to expand and develop at a rapid pace, anesthesiologists are increasingly called upon to provide well tolerated anesthetic care during these procedures. These patients may not be candidates for surgical treatment and often have multiple comorbidities. It is important for anesthesiologists to familiarize themselves with these procedures and their associated risks and complications. The scope of the interventional pulmonologist's practice is varied and includes both diagnostic and therapeutic procedures. Bronchial thermoplasty is now offered as endoscopic treatment of severe asthma. Endobronchial lung volume reduction procedures are currently undergoing clinical trials and may become more commonplace. Interventional pulmonologists are performing medical thoracoscopy for the treatment and diagnosis of pleural disorders. Interventional radiologists are performing complex pulmonary procedures, often requiring anesthesia. The review summarizes the procedures now commonly performed by interventional pulmonologists and interventional radiologists. It discusses the anesthetic considerations for and common complications of these procedures to prepare anesthesiologists to safely care for these patients. Investigational techniques are also described.

Neurostimulation Devices Used in Treatment of Epilepsy.

Epilepsy is a chronic neurological disorder frequently requiring lifelong treatment. In 70% of epilepsy patients, seizures are well controlled by antiepileptic medications. About 30% of epilepsy patients remain refractory to medical treatments and may need surgical interventions for better seizure control. Unfortunately and not infrequently, surgical intervention is not feasible due to various reasons such as multiple seizure foci, not resectable focus because of eloquent cortex location, or inability to tolerate surgery due to ongoing concomitant medical conditions. Neurostimulation devices have provided possible seizure control for refractory epilepsy patients who are not candidates for surgical intervention. Among them, vagal nerve stimulation (VNS) has been the oldest, in use since 1997. VNS was followed by responsive nerve stimulation (RNS) after obtaining FDA approval in 2013. Deep brain stimulation (DBS) has not yet met approval in the USA, but has been in clinical practice in Europe since 2010. Neurostimulation devices vary in how they are inserted and their mechanisms of action. VNS has been easily accepted by patients since it is placed extracranially. By contrast, DBS and RNS require invasive procedures for intracranial implantation. As use of these devices will continue to increase in the foreseeable future, we aimed to contribute to the foundation for new research to expand on current knowledge and practice by reviewing the current status of the literature.

Does Adjunctive Tigecycline Improve Outcomes in Severe-Complicated, Nonoperative Clostridium difficile Infection?

Severe Clostridium difficile infection is associated with a high rate of mortality; however, the optimal treatment for severe- complicated infection remains uncertain for patients who are not candidates for surgical intervention. Thus, we sought to evaluate the benefit of adjunctive tigecycline in this patient population using a retrospective cohort adjusted for propensity to receive tigecycline. We found that patients who received tigecycline had similar outcomes to those who did not, although the small sample size limited power to adjust for comorbidities and severity of illness.

Approaches to surgical staging of cancer of the uterine cervix

Cancer of the uterine cervix is staged using a clinical, rather than a surgical staging system, which is the approach used for other gynecologic tumors. Surgical staging is potentially more accurate. However, the International Federation of Gynecology and Obstetrics (FIGO) has determined that clinical staging is preferable for assessing locally advanced disease (i. e., tumor size, vaginal and parametrial involvement); and it allows to avoid surgery in women who are not candidates for surgical treatment. The staging and pelvic and paraaortic lymph node evaluation for cervical cancer are reviewed here.