Preoperative Medical Management Research Articles

Inflammation and Cognitive Dysfunction in Type 2 Diabetic Carotid Endarterectomy Patients

OBJECTIVEType 2 diabetic patients have a high incidence of cerebrovascular disease, elevated inflammation, and high risk of developing cognitive dysfunction following carotid endarterectomy (CEA). To elucidate the relationship between inflammation and the risk of cognitive dysfunction in type 2 diabetic patients, we aim to determine whether elevated levels of systemic inflammatory markers are associated with cognitive dysfunction 1 day after CEA.RESEARCH DESIGN AND METHODSOne hundred fifteen type 2 diabetic CEA patients and 156 reference surgical patients were recruited with written informed consent in this single-center cohort study. All patients were evaluated with an extensive battery of neuropsychometric tests. Preoperative monocyte counts, HbA1c, C-reactive protein (CRP), intercellular adhesion molecule 1, and matrix metalloproteinase 9 activity levels were obtained.RESULTSIn a multivariate logistic regression model constructed to identify predictors of cognitive dysfunction in type 2 diabetic CEA patients, each unit of monocyte counts (odds ratio [OR] 1.76 [95% CI 1.17–2.93]; P = 0.005) and CRP (OR 1.17 [1.10–1.29]; P < 0.001) was significantly associated with higher odds of developing cognitive dysfunction 1 day after CEA in type 2 diabetic patients.CONCLUSIONSType 2 diabetic patients with elevated levels of preoperative systemic inflammatory markers exhibit more cognitive dysfunction 1 day after CEA. These observations have implications for the preoperative medical management of this high-risk group of surgical patients undergoing carotid revascularization with CEA.

Preoperative Medication Management

Preoperative medication management is central to the delivery of high-quality surgical care. The successful management of patients through an operation must address medication concerns related to anesthesia, individual patient care needs, and the surgical procedure itself. The number of patients who require preoperative medication management is formidable, with half of all patients undergoing surgery on some type of medication. 1 Moreover, the number of medications and complexity of management increase with patients who often require surgery, namely older patients and those with multiple comorbidities. Largely because of adverse events in medication management, patients taking medications before surgery have a three times higher risk of postoperative complications than those who are not taking medications. 2 Effective preoperative management of medications is a critical part of optimizing a patient’s clinical status for best possible outcomes before, during, and after surgical procedures. Despite the abundance of literature available on preoperative and perioperative management, significant gaps remain for providers caring for surgical patient populations at high risk for poor outcomes. 3 Prior reviews of preoperative medication management have attempted to present evidence on this broad and potentially unwieldy topic. These data are challenging, not only because the topic is vast but also because data are often limited and insufficient to provide evidence-based recommendations. 4,5 Past re

Gamma Knife in the Treatment of Pituitary Adenomas: Results of a Single Center

Gamma Knife (GK) radiosurgery for pituitary adenomas can offer a means of tumor and biologic control with acceptable risk and low complication rates. Retrospective review of all the patients treated at our center with GK for pituitary adenomas from Nov 2003 to June 2011. We treated a total of 86 patients. Ten were lost to follow-up. Mean follow was 32.8 months. There were 21 (24.4%) growth hormone secreting adenomas (GH), 8 (9.3%) prolactinomas (PRL), 8 (9.3%) adrenocorticotropic hormone secreting (ACTH) adenomas, 2 (2.3%) follicle stimulating hormone/luteinizing hormone secreting (FSH/LH) adenomas, and 47 (54.7%) null cell pituitary adenomas that were treated. Average maximum tumor diameter and volume was 2.21cm and 5.41cm³, respectively. The average dose to the 50% isodose line was 14.2 Gy and 23.6 Gy for secreting and non-secreting adenomas respectively. Mean maximal optic nerve dose was 8.87 Gy. Local control rate was 75 of 76 (98.7%), for those with followup. Thirty-three (43.4%) patients experienced arrest of tumor growth, while 42 (55.2%) patients experienced tumor regression. Of the 39 patients with secreting pituitary tumors, 6 were lost to follow-up. Improved endocrine status occurred in 16 (50.0%), while 14 (43.8%) demonstrated stability of hormone status on continued pre-operative medical management. Permanent complications included: panhypopituitarism (4), hypothyroidism (4), hypocortisolemia (1), diabetes insipidus (1), apoplexy (1), visual field defect (2), and diplopia (1). Gamma Knife radiosurgery is a safe and effective means of achieving tumor growth control and endocrine remission/stability in pituitary adenomas.

Modern Rectal Cancer Multidisciplinary Treatment: The Role of Radiation and Surgery

Treatment of rectal cancer has evolved during the last few decades due to more in-depth knowledge of rectal cancer biology and major advances in the field of preoperative staging, medical management and surgical techniques. Consequently, treatment strategies are shifting moving towards a more personalized approach based on the response to treatment. Currently topics of controversy are centered around the indication for neoadjuvant radiation therapy in locally advanced rectal cancer and the role of surgery in patients with complete clinical response after neoadjuvant combined modality therapy. This manuscript aims to critically evaluate the evolution of treatment of rectal cancer during the last three decades and future directions. A review of the literature has been performed in PubMed/Medline electronic databases. Treatment modalities are moving towards a tailored approach to rectal cancer patients based on the response to chemoradiation. A "wait-and-see" approach and local excision by Transanal Endoscopic Microsurgery (TEM) are strategies recently proposed in case of complete clinical response. The standard of care still requires that locally advanced rectal cancer should be treated by neoadjuvant chemoradiation therapy followed by total mesorectal excision, including patients with a clinical complete response. Further evidence is needed to endorse a "wait-and-see" strategy and to define the role of TEM.

Multimodality molecular imaging in the evaluation of pheochromocytoma. A case report

<dm:abstracts xmlns:dm="http://www.elsevier.com/xml/dm/dtd"><ce:abstract xmlns:ce="http://www.elsevier.com/xml/common/dtd" id="ab0005" view="all" class="author"><ce:abstract-sec id="abs0005" view="all"><ce:section-title id="sect0005">Summary</ce:section-title><ce:simple-para id="sp0005" view="all">Pheochromocytoma is an uncommon tumor that can present a significant perioperative challenge, potentially resulting in hemodynamic instability necessitating the use of multiple vasoactive agents. On rare occasion, malignant pheochromocytomas are encountered which can invade adjacent structures, including the inferior vena cava (IVC), necessitating IVC cross-clamping to achieve surgical resection. In this case conference, we review the case of a 28 year-old man who presented with hypertension, nausea, and vomiting and was found to have a large malignant pheochromocytoma with IVC invasion. We detail his clinical course throughout the perioperative period, with discussion focusing on preoperative medical management, intraoperative hemodynamic and surgical considerations, and postoperative complications and management in the ICU setting.</ce:simple-para></ce:abstract-sec></ce:abstract></dm:abstracts>

Preoperative Cardiac Risk Assessment and Medical Management for Noncardiac Surgery

Advanced practice nurses (APNs) often care for patients who have risks for postoperative cardiac complications and face noncardiac surgery. Surgical urgency determines the initial preoperative evaluation, and the immediate action before emergency surgery is to identify high-risk patients and provide appropriate risk reduction. An elective surgery in those with active cardiac disease should be postponed until cardiac evaluation and treatment are complete. Asymptomatic patients may be risk stratified, and the revised cardiac risk index is easy to use and widely adopted. APNs have the opportunity to assess patient risk and take appropriate actions to minimize cardiac complications.

Laparoscopic splenectomy for immune thrombocytopenia (ITP) patients with platelet counts lower than 1 × 109/L

Laparoscopic splenectomy (LS) has become the gold-standard surgical intervention for the treatment of immune thrombocytopenia (ITP) and the patients who experienced medical relapse to steroid. Fewer series are available regarding LS for patients with an extremely low platelet count. The aim of this study is to investigate the feasibility and safety of laparoscopic splenectomy in the treatment of patients with a preoperative platelet count of less than 1 × 109/L. From April 2006 to Jan 2011, 10 patients were managed by laparoscopic splenectomy for idiopathic thrombocytopenia with an extremely low preoperative platelet count. Preoperative, perioperative, and postoperative medical management has been reviewed. Before laparoscopic splenectomy, all of the 10 patients had a platelet count of less than 1 × 109/L but a normal level of coagulation function. Emergency laparoscopic splenectomy was performed. The mean operating time was 157 min; the mean intraoperative blood loss was 44 mL. During the operations, transfusion was provided in two patients. No intraoperative complications ensued. The patients were followed up for a mean of 28 months and showed good recovery without any postoperative complications. Laparoscopic splenectomy is a feasible technique in the treatment of ITP patients, characterized by severe mucocutaneous bleeding, extremely low platelet count, and normal prothrombin time (PT) and activated partial thromboplastin time (APTT).

Postoperative cognitive disorders

The elderly are the fastest growing segment of the population and undergo 25-30% of all surgical procedures. Postoperative cognitive problems are common in older patients following major surgery. The socioeconomic implications of these cognitive disorders are profound; cognitive decline is associated with a loss of independence, a reduction in the quality of life, and death. This review will focus on the two most common cognitive problems following surgery: postoperative delirium and postoperative cognitive dysfunction (POCD). For years, preoperative geriatric consultation/screening was the only intervention proven to decrease postoperative delirium. There are, however, several recent publications indicating that preoperative and postoperative pharmacological and medical (hydration, oxygenation) management can reduce postoperative delirium. Spinal anesthesia with minimal propofol sedation has been shown to decrease the incidence of postoperative delirium in hip-fracture patients. Likewise, dexmedetomidine sedation in mechanically ventilated patients in the ICU is associated with less postoperative delirium and shorter ventilator times. Preoperative levels of education and brain function (cognitive reserve) may predict patients at risk for postoperative cognitive problems. Reduced white matter integrity is reported to place patients at a higher risk for both postoperative delirium and POCD. The etiology of postoperative cognitive problems is unknown, but there is emerging evidence that decreased preoperative cognitive function contributes to the development of postoperative delirium and POCD. There is growing concern that inhalation anesthetics may be neurotoxic to the aging brain, but there are no human data evaluating this hypothesis to date. Randomized controlled trials evaluating interventions to improve long-term cognitive outcomes in elderly patients are urgently needed.

Sauk Prairie Memorial Hospital &amp; Clinics Perioperative Diabetes Medication Management Guidelines

Patients arrived at Sauk Prairie Memorial Hospital & Clinics, for surgeries and or procedures with uncontrolled hyperglycemia. An inconsistency in preoperative diabetes medication management was identified. Patients were receiving preoperative diabetes management instructions that were not evidence-based.

Preparedness for internship: a survey of new interns in a large Victorian Health Service

To gain better understanding of the work-preparedness of new interns and identify areas where further training and education should be provided. Surveys of new interns assessing self-reported confidence and preparedness for tasks commonly undertaken without direct supervision. The first survey was undertaken before the cohort had started work, the second once they had completed their second intern rotation. A large metropolitan Victorian health service. All interns starting in 2009 at Southern Health. Of the total 66 interns, 52 (84%) completed the first survey and 37 (56%) completed the second. Self-reported confidence and preparedness for common intern tasks. The surveys identified tasks that interns undertake frequently, their preparedness for these and their confidence in completing them. Although most felt reasonably well prepared by their university training for many tasks they commonly undertake as interns, this was not the case for all tasks. In particular, they did not feel well prepared for the following: preoperative patient review, handover, fluid and medication management, patient admissions, assessment of unstable patients, communication with patients and families, and pain management. There are particular domains of work-readiness for interns that could be improved. For best results, the training of interns in these common tasks should be undertaken jointly by hospitals and universities to ensure smooth transition from medical student to intern.

Management of paroxysmal hypertension due to incidental pheochromocytoma in pregnancy

A 25-year-old, full-term pregnant woman diagnosed with pre-eclampsia was referred to our tertiary care hospital with severe resistant hypertension. Her blood pressure remained labile despite the usual medications, which led to the suspicion of an underlying endocrinological problem. Further biochemical and radiological investigations confirmed the diagnosis of pheochromocytoma. The patient was invasively monitored and treated with alpha blockade, beta blocker, and vasodilators. The primary goals for the management of pheochromocytoma in pregnancy are early diagnosis, avoidance of a hypertensive crisis during delivery, and definitive surgical treatment. This case illustrates that one needs to be cautious when such a presentation of paroxysmal hypertension is present. With a multidisciplinary team approach, proper planning, and adequate preoperative medical management, pheochromocytoma in pregnancy can be managed successfully.

V765 LAPAROSCOPIC ADRENALECTOMY FOR PHEOCHROMOCYTOMA ASSOCIATED WITH HORSESHOE KIDNEY

You have accessJournal of UrologyOncology (TCC & Adrenal) & Teaching Techniques1 Apr 2010V765 LAPAROSCOPIC ADRENALECTOMY FOR PHEOCHROMOCYTOMA ASSOCIATED WITH HORSESHOE KIDNEY Thomas Christiano, Nitin Patel, Jennifer Yates, Jayant Uberoi, and Ravi Munver Thomas ChristianoThomas Christiano More articles by this author , Nitin PatelNitin Patel More articles by this author , Jennifer YatesJennifer Yates More articles by this author , Jayant UberoiJayant Uberoi More articles by this author , and Ravi MunverRavi Munver More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1359AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Adrenal pheochromocytoma is associated with various genetic syndromes including multiple endocrine neoplasia and neurofibromatosis type 1 (NF-1). Patients with NF-1 are more likely to have renal anomalies including a horseshoe kidney. Laparoscopic adrenalectomy is the standard technique for the surgical removal of benign adrenal masses, including pheochromocytoma. This video illustrates the excision of a right adrenal pheochromocytoma in a patient with neurofibromatosis and a horseshoe kidney. METHODS A 62 year old female with NF-1 was referred for a diagnosis of a right adrenal mass. Radiographic characteristics and endocrinologic evaluation revealed the mass to be consistent with a pheochromocytoma in the setting of a horseshoe kidney. The patient elected surgical management via a laparoscopic approach. Appropriate preoperative medical management was instituted. RESULTS A transperitoneal approach was employed with the use of 4 trocars, including three 5 mm trocars and one 12 mm trocar. The procedure began with extensive mobilization of the liver. An upper pole renal artery and vein were noted to be in close proximity to the inferior border of the adrenal gland as they coursed to the kidney from a cephalad direction. Meticulous dissection resulted in identification of the inferior vena cava and a large hepatic vein. Further dissection revealed an anomalous main adrenal vein that drained into the hepatic vein. The adrenal vein was dissected, ligated with clips, and transected with a bipolar vessel-sealing device. The upper, lateral, and inferior attachments of the adrenal gland were dissected from surrounding structures and the adrenal gland was placed into a laparoscopic bag and extracted. The operative time was 104 minutes and blood loss was 5 milliliters. The patient was discharged home on the first postoperative day without complication. Final pathology revealed a 3.5 cm pheochromocytoma. CONCLUSIONS Laparoscopic adrenalectomy in the setting of a horseshoe kidney may be complicated by anomalous anatomy. In particular, anomalies or multiplicity of the adrenal vessels or renal hilar vessels must be suspected. Cautious dissection and recognition of potential abnormalities can result in successful minimally-invasive removal of the adrenal gland in patients with horseshoe kidneys. Hackensack, NJ© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e299 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thomas Christiano More articles by this author Nitin Patel More articles by this author Jennifer Yates More articles by this author Jayant Uberoi More articles by this author Ravi Munver More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Adrenocortical carcinoma: role of laparoscopic surgery in treatment

Adrenocortical carcinoma is a rare disorder with a prevalence of one case per 1.7 million people and a generally poor prognosis. It accounts for 0.02% of all cancer cases and 0.2% of cancer deaths. Within the past three decades, accurate diagnosis, precise radiologic localization, satisfactory preoperative medical management, appropriate anesthesia and refined surgical techniques have come together to render the surgical management of adrenal abnormalities a safe endeavor with predictable outcomes. While there is a general agreement on the suitability of the laparoscopic approach for benign adrenal lesions, controversy remains regarding the use of laparoscopy for suspected adrenal malignancies. This paper provides an overview of adrenal cancer and reviews the literature on laparoscopic adrenalectomy for cancer, including the operative techniques, indications and contraindications.

Greater Palatine Island Axial Pattern Flap for Repair of Oronasal Fistula Related to Eosinophilic Granuloma

A Greyhound presented with eosinophilic granuloma lesions of the soft palate and oronasal fistula. Since other siblings had been known to also have oral eosinophilic granuloma, it was suspected that the dog reported here had a familial predisposition to develop the disease. Preoperative medical management consisting of anti-inflammatory and immunosuppressive therapy was required before surgical repair of the oronasal fistula. Multiple surgical techniques, including a greater palatine island axial pattern flap, were used to repair the oronasal fistula.

Associations Between the Hospitalist Model of Care and Quality-of-Care-Related Outcomes in Patients Undergoing Hip Fracture Surgery

To investigate the relationship between the hospitalist consultant model of care and both length of hospital stay (LOS) and hospital cost for patients undergoing hip fracture surgery. We retrospectively studied 118 consecutive patients admitted with hip fracture (diagnosis related groups 79.35 and 81.52) between January 1, 2002, and December 31, 2002, at a community-based academic medical center. For each patient, consultations for preoperative medical evaluation and management of postoperative complications were performed by a hospitalist or a traditional medical consultant (nonhospitalist). We defined "hospitalist" as dedicated hospital-based physicians who provide their maximum professional time in inpatient health care delivery and who are completely free of outpatient responsibilities. Time to consultation (TTC), time to surgery (TTS), LOS, and total hospital costs were determined for each patient by review of the medical records and were compared between hospitalist and nonhospitalist consultants. Both TTC and TTS were significantly lower for hospitalist patients (P < .001 and P = .004, respectively). Although not statistically significant, cost and LOS also were lower for patients receiving hospitalist care. In the hospitalist group, median cost was an estimated dollar 1777 less, and median LOS was 1 day less than in the nonhospitalist group. Hospitalist Involvement in the medical management of patients undergoing hip fracture surgery may be associated with decreases in TTC, TTS, LOS, and total hospital cost. The results of this study have implications for consultative medical care of patients undergoing urgent surgery and their health outcomes.

Predictors of perioperative complications in head and neck patients.

Patients with significant medical problems requiring major otolaryngology procedures are at high risk for both medical and surgical complications. To identify risk factors associated with perioperative complications in medically compromised patients undergoing major otolaryngology procedures. Ninety-three consecutive patients with significant comorbid medical illnesses (eg, diabetes, hypertension) undergoing major head and neck surgical procedures were referred to a medical consultation center for preoperative assessment and medical management. Patient and surgical characteristics as well as perioperative complications were identified and recorded. Univariate and multivariate analyses were performed to determine which characteristics were associated with complications. Thirty-two patients (34%) had postoperative complications. Twenty-six patients (28%) had serious medical complications, and 18 (19%) had surgical complications. No deaths occurred in the study population. On univariate analysis, the factors associated with all complications included history of hepatitis, flap reconstruction, oncologic surgery, preoperative radiation therapy, preoperative gastrostomy placement, intraoperative transfusion, anesthesia time (> or =8 hours), and those with greater intraoperative fluid replacement and estimated blood losses. Only anesthesia time (> or =8 hours) remained independently significant on multivariate analysis. A history of hepatitis and prolonged anesthesia time were the only independent predictors of medical complications. The only independent predictor of surgical complications was the volume of intraoperative fluid administered. Prolonged anesthesia times of 8 hours or more, a history of hepatitis, and large-volume intraoperative fluid resuscitations predicted adverse outcomes. Special care must be taken in counseling these patients preoperatively and in caring for them during their operative and postoperative course.

Pheochromocytoma.

The only definitive therapy for patients with pheochromocytoma is surgical resection [1,2**]. Advances in preoperative medical management of hypertension/hypovolemia and improved intraoperative anesthetic care have reduced the operative mortality rate for pheochromocytoma to less than 5% in most series. In addition, accurate preoperative localization studies have eliminated the need for extensive exploratory laparotomy. Focused approach and laparoscopic resection have become the new "gold standard," with a reduced morbidity [4**]. Large or locally invasive pheochromocytomas may still require open resection.

Laparoscopic surgery for Crohn's disease: reasons for conversion.

To examine factors influencing conversion from a laparoscopic to an open procedure in patients requiring surgery for Crohn's disease. Laparoscopic management of patients with complications of Crohn's produces better outcomes than traditional open approaches, but it is difficult to determine before surgery who will be amenable to laparoscopic management. In this series, a laparoscopic approach was offered to virtually all patients to determine reasons for laparoscopic failure. Data regarding patients who underwent attempted laparoscopic procedures for Crohn's (January 1993 to June 2000) were collected prospectively. The bowel was mobilized laparoscopically and extracorporeal anastomoses were performed. Conversion to open surgery was defined as creation of an incision of more than 5 cm. One hundred ten patients (age 37 +/- 1.1 years, 58% female) underwent 113 attempted laparoscopic interventions. Indications for surgery included obstruction (77%), failure of medical management (35%), fistula (27%), and perineal sepsis (4%). Sixty-eight procedures (60%) were completed laparoscopically. Procedures completed laparoscopically included ileocecectomy (n = 46), small bowel resection (n = 22), fecal diversion (n = 7), intestinal stricturoplasty (n = 7), resection of prior ileocolonic anastomosis (n = 5), segmental colectomy (n = 1), and lysis of adhesions (n = 1). Forty-five procedures (40%) were converted as a result of adhesions (n = 21), extent of inflammation or disease (n = 9), size of the inflammatory mass (n = 7), inability to dissect a fistula (n = 5), or inability to assess anatomy (n = 3). Factors associated with conversion were internal fistula as an indication for surgery, smoking, steroid administration, extracecal colonic disease, and preoperative malnutrition. In laparoscopic patients, mean times to passage of flatus and first bowel movement were 3.6 +/- 0.2 days and 4.4 +/- 0.2 days, respectively. Mean time to discharge was 6 +/- 0.2 days. Attempted laparoscopic management is safe and effective if there is an appropriate threshold for conversion to an open procedure. Conversion factors identified in this study largely reflect technical challenge and severity of disease. Patients taking steroids and those with known fistulas or colonic involvement threaten laparoscopic failure, but many of these patients can be managed laparoscopically and have better outcomes. By understanding the reasons for conversion, it is hoped that the chances of laparoscopic success can be improved by modifying standard preoperative medical management or using additional technological capabilities (e.g., robotics).

Operations on patients deemed "unfit for operation and anaesthesia": what are the consequences?

The decision "patient unfit for anaesthesia and operation" is likely to cause a delay of the scheduled operation. This retrospective evaluation was done: 1) to determine the correctness of preoperative tentative diagnoses of coexisting diseases making anaesthesia and operation excessively risky in relation to the physician's training status; 2) to examine the question of whether preoperative medical management modified according to the anaesthesiologist's suggestions had a positive impact on the perioperative course. The medical records of patients scheduled for elective non-cardiac surgery who were rated "unfit for operation and anaesthesia" were evaluated. The accuracy of the tentative diagnoses was examined for relation to the training status of the anaesthesiologists. The preoperative management was tested for its impact on postoperative outcome. During the observation period 16,122 patients underwent preoperative anaesthesiological assessment; 1021 (6.3%) were initially considered to be unfit for operation and anaesthesia. The records of 807 patients were available for review. The accuracy of the tentative diagnoses was 70%, and was not significantly affected by the training status of the physicians (P = 0.022). Four hundred and seventeen patients were excluded from the second part of the investigation (discharged without operation, underwent operation using local anaesthesia or tentative diagnosis not confirmed). Three hundred and ninety patients were operated under general anaesthesia. Group I (n = 216) was managed according to the anaesthesiologist's suggestions and was found to have a significantly lower complication rate (18.1%) than group II (n = 174) in which the suggestions from the preoperative assessment were ignored (32.2%; P < 0.05). The perioperative mortality rate in group I was 2.3% compared with 5.2% in group II (n.s.; P > 0.05). We conclude that the anaesthesiology decision "patient unfit for operation and anaesthesia" has a high accuracy, independent of the anaesthesiologist's training status, and that preoperative medical management significantly reduces complications.

A cost-effectiveness analysis of anterior temporal lobectomy for intractable temporal lobe epilepsy.

Patients with medically intractable temporal lobe epilepsy are potential candidates for anterior temporal lobectomy (ATL), in which epileptogenic temporal lobe tissue is localized and surgically removed. This surgical approach can eliminate or drastically reduce seizures in the majority of patients. The authors used a decision-analysis model to examine the cost-effectiveness of a surgical evaluation and treatment protocol for medically intractable temporal lobe epilepsy. This model compared a cohort treated with the new protocol with a continuation of their immediate preoperative medical management and projected these differences over the patient's lifetime. The Markov model incorporated postoperative seizure status, patient quality of life, death from surgical and natural causes, discounting, and the direct medical costs associated with outpatient evaluation, hospitalization, surgery, antiepileptic drugs, and lifetime outpatient treatment. The intent-to-treat analysis included patients who underwent evaluation but were not eligible for ATL. Sensitivity analyses were also performed on the variables in the model. Data from the baseline model indicated that evaluation for ATL provided an average of 1.1 additional quality-adjusted life years (QALYs) compared with continued medical management, at an additional cost of $29,800. Combining the clinical and economic outcomes yielded a cost-effectiveness ratio of $27,200 per QALY. This value is comparable to other accepted medical or surgical interventions, such as total knee arthroplasty ($16,700/QALY) or coronary artery balloon angioplasty ($40,800/QALY). Sensitivity analyses demonstrate that the results are critically dependent on postoperative seizure status and improvement in quality of life. Although further work is necessary to quantify the improvement in quality of life after epilepsy surgery better, the present data indicate that ATL for treatment of intractable temporal lobe epilepsy is a cost-effective use of medical resources.