Preoperative Surgical Evaluation Research Articles

Despite Greater Improvement in Pain and Function Among Obese Patients Shortly After Total Knee Arthroplasty, There is No Difference in Patient-Reported Outcomes and Satisfaction Between Body Mass Index Classes at 1 Year Postoperatively

BackgroundAlthough obesity may be associated with an increased risk of perioperative and postoperative complications after total knee arthroplasty (TKA), body mass index (BMI) cutoffs for TKA patient selection remain a controversial topic. This study aimed to investigate patient-reported outcomes, satisfaction, and pain among BMI classes at 3 months and 1 year following TKA. MethodsA total of 2,365 patients were categorized into Centers for Disease Control BMI classes according to preoperative values. The BMI distribution over the cohort demonstrated 7 underweight, 340 healthy weight, 731 overweight, 666 Class I, 391 Class II, and 230 Class III obesity. Preoperative and postoperative Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), satisfaction, and pain scores were compared by BMI class by Analysis of Variance with pairwise comparisons. ResultsPreoperative KOOS JR scores and satisfaction scores were both significantly greater for healthy weight patients compared to Class III patients (P < .0001). However, KOOS JR, satisfaction, and pain did not vary by BMI class postoperatively. Changes in scores from baseline suggest larger improvements with increasing BMI class, where Class III patients reported the greatest improvements in KOOS JR (23.24 ± 15.67, P < .0001) and pain scores (−3.56 ± 2.65, P < .0001) at 90 days. Significantly greater improvement with increasing BMI was also present at 1-year postoperatively for KOOS JR scores. A total of 85.8% of Class III patients reached the Minimal Clinically Important Difference for KOOS JR at 90 days compared to 76.8% of the healthy weight group (P = .03). Differences between BMI groups in the proportion reaching Minimal Clinically Important Difference at 1 year were not significant. ConclusionsPatients of higher BMI reported greater and earlier improvements in satisfaction, knee function, and pain following TKA. Shared decision-making remains paramount to preoperative surgical evaluation. However, rationing of this surgical intervention based on BMI alone may not be warranted.

Lessons learned from the COVID-19 pandemic: Using telemedicine for pre-operative surgical evaluation in breast disease.

The COVID-19 pandemic motivated telemedicine care to decrease potential exposures for both patients and staff. We hypothesized that select breast surgical patients can be successfully evaluated pre-operatively with telemedicine. With institutional review board approval, patients with telemedicine surgical consults between 1 March 2020 and 31 August 2020 were identified retrospectively from our prospective breast surgical registry. The frequency of successful pre-operative evaluation using telemedicine alone was assessed, defined as cases in which surgery was completed on the planned day without changes to the surgical plan after physical examination in the pre-operative area. Differences in disease presentation, patient characteristics, and complications were evaluated by whether the first in-person visit occurred on the day of surgery versus the prior. A total of 374 patients underwent breast surgery between 1 March 2020 and 31 August 2020, of which 96 (25.7%) had a telemedicine consultation. After the telemedicine visit, 38 patients (39.6%) had additional in-person visits with the breast surgeon prior to their operative date, and 58 patients (60.4%) did not. Forty-five patients underwent breast-conserving therapies, 41 mastectomies (25 with reconstruction), two axillary dissections, and eight excisional biopsies. All surgeries were completed on the planned operative day, with no changes in surgical plans. Patients with telemedicine only prior to surgery were more likely to speak English (100% vs. 92.1%, p = 0.02) and have lower body mass index (median 24.9 vs. 29.2, p = 0.01). The frequency of in-person pre-operative visits varied significantly by surgeon (p < 0.001). Age, American Society of Anaesthesiologists score, distance from facility, clinical T/N category, surgery type, and complications did not differ between groups. Telemedicine can be utilized successfully for select breast surgical patients, with the ability to proceed to surgery in the majority of patients without additional in-person visits.

Clinical Outcomes and Hospital Utilization Among Patients Undergoing Bariatric Surgery With Telemedicine Preoperative Care

Bariatric surgery is the mainstay of treatment for medically refractory obesity; however, it is underutilized. Telemedicine affords patient cost and time savings and may increase availability and accessibility of bariatric surgery. To determine clinical outcomes and postoperative hospital utilization for patients undergoing bariatric surgery who receive fully remote vs in-person preoperative care. This cohort study comparing postoperative clinical outcomes and hospital utilization after telemedicine or in-person preoperative surgical evaluation included patients treated at a US academic hospital. Participants underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy after telemedicine or in-person preoperative surgical evaluation between July 1, 2020, to December 22, 2021, or January 1, 2018, to December 31, 2019, respectively. Follow-up was 60 days from date of surgery. Telemedicine-based preoperative care. Clinical outcomes, including operating room delay, procedure duration, length of hospital stay (LOS), and major adverse events (MAE), and postoperative hospital resource utilization, including emergency department (ED) visit or hospital readmission within 30 days of the surgical procedure. A total of 1182 patients were included; patients in the telemedicine group were younger (mean [SD] age, 40.8 [12.5] years vs 43.0 [12.2] years; P = .01) and more likely to be female (230 of 257 [89.5%] vs 766 of 925 [82.8%]; P = .01) compared with the control group. The control group had a higher frequency of comorbidity (887 of 925 [95.9%] vs 208 of 257 [80.9%]; P < .001). The telemedicine group was found to be noninferior to the control group with respect to operating room delay (mean [SD] minutes, 7.8 [25.1]; 95% CI, 5.1-10.5 vs 4.2 [11.1]; 95% CI, 1.0-7.4; P = .002), procedure duration (mean [SD] minutes, 134.4 [52.8]; 95% CI, 130.9-137.8 vs 105.3 [41.5]; 95% CI, 100.2-110.4; P < .001), LOS (mean [SD] days, 1.9 [1.1]; 95% CI, 1.8-1.9 vs 2.1 [1.0]; 95% CI, 1.9-2.2; P < .001), MAE within 30 days (3.8%; 95% CI, 3.0%-5.7% vs 1.6%; 95% CI, 0.4%-3.9%; P = .001), MAE between 31 and 60 days (2.2%; 95% CI, 1.3%-3.3% vs 1.6%; 95% CI, 0.4%-3.9%; P < .001), frequency of ER visits (18.8%; 95% CI, 16.3%-21.4% vs 17.9%; 95% CI, 13.2%-22.6%; P = .03), and hospital readmission (10.1%; 95% CI, 8.1%-12.0% vs 6.6%; 95% CI, 3.9%-10.4%; P = .02). In this cohort study, clinical outcomes in the telemedicine group were not inferior to the control group. This observation suggests that telemedicine can be used safely and effectively for bariatric surgical preoperative care.

Hepato-pancreato-biliary surgery in Mexico and Latin America during the COVID-19 pandemic (2020): Results from AMHPB survey.

The Mexican Hepato-Pancreato-Biliary Association (AMHPB) conducted a survey, aiming to gather experience and opinions of HPB surgeons about HPB surgery in the 2020 COVID-19 pandemic year. An online survey was conducted (33 items: demographics, patient referral, COVID-19 screening and limitations, hospital occupancy and surgical practice) to AMHPB members and attendees of the previous meetings of the Society through a self-administered questionnaire. Answers were excluded if respondents were not from Latin America. 88 participants answered (47.5 ± 10 years, 94% male and 65.9% Mexicans). About 8% worked in COVID-19 converted hospitals. About 1.1% did not perform pre-operative COVID-19 testing. Polymerase chain reaction (33%) was the most common COVID-19 pre-operative test. The number of patient referrals decreased 62.5%. About 29.5% had one patient who died from COVID-19 during preoperative surgical evaluation. About 64.7% answered that surgical case volume decreased. About 17% and 23% respondents considered that surgical morbidity and mortality increased, respectively. Hospital resources and COVID-19 infection were responsible for change in surgical outcomes. Lack of ICU beds (54%) was the most common cause of surgical cancellation. COVID-19 had a strong negative impact on HPB surgery in Mexico and Latin America in terms of patient reference, case volume and surgical outcomes.

Atlas-based segmentation of cochlear microstructures in cone beam CT.

To develop an automated segmentation approach for cochlear microstructures [scala tympani (ST), scala vestibuli (SV), modiolus (Mod), mid-modiolus (Mid-Mod), and round window membrane (RW)] in clinical cone beam computed tomography (CBCT) images of the temporal bone for use in surgical simulation software and for preoperative surgical evaluation. This approach was developed using the publicly available OpenEar (OE) Library that includes temporal bone specimens with spatially registered CBCT and 3D micro-slicing images. Five of these datasets were spatially aligned to our internal OSU atlas. An atlas of cochlear microstructures was created from one of the OE datasets. An affine registration of this atlas to the remaining OE CBCT images was used for automatically segmenting the cochlear microstructures. Quantitative metrics and visual review were used for validating the automatic segmentations. The average DICE metrics were 0.77 and 0.74 for the ST and SV, respectively. The average Hausdorff distance (AVG HD) was 0.11mm and 0.12mm for both scalae. The mean distance between the centroids for the round window was 0.32mm, and the mean AVG HD was 0.09mm. The mean distance and angular rotation between the mid-modiolar axes were 0.11mm and 9.8 degrees, respectively. Visually, the segmented structures were accurate and similar to that manually traced by an expert observer. An atlas-based approach using 3D micro-slicing data and affine spatial registration in the cochlear region was successful in segmenting cochlear microstructures of temporal bone anatomy for use in simulation software and potentially for pre-surgical planning and rehearsal.

The Impact of Mental Illness on Postoperative Outcomes Among Medicare Beneficiaries: A Missed Opportunity to Help Surgical Patients?

The aim of this study was to define the prevalence of preexisting mental illness, as well as characterize the impact of a preexisting mental illness diagnosis on postoperative outcomes. Preoperative surgical evaluation and risk stratification have traditionally centered on optimizing physical health. The influence of mental health on postoperative surgical outcomes has not been investigated. Medicare beneficiaries who underwent elective colectomy, coronary artery bypass grafting, abdominal aortic aneurysm repair, abdominal aortic aneurysm repair, total hip arthroplasty, total knee arthroplasty, and lung resection were identified. Patients were classified as having mental illness using International Classification of Diseases, 9th and 10th Revisions Procedures codes (ICD9/10CM) codes for anxiety, depression, bipolar disorder, schizophrenia, or other psychotic disorder. Among 1,889,032 Medicare beneficiaries who met inclusion criteria 560,744 (n = 29.7%) individuals had an antecedent diagnosis of mental illness. The majority had anxiety and/or depression (91.8%), whereas a smaller subset (8.2%) had a severe mental illness diagnosis. Patients who did and did not have mental illness were comparable relative to age and comorbidities. Patients with preoperative mental illness had a higher chance of surgical complications [anxiety/depression odds ratio (OR) 1.44, 95% confidence interval (CI) 1.42-1.46, severe mental illness OR 1.71, 95%CI 1.66-1.77] and an extended length of stay (anxiety/depression OR 1.45, 95% CI 1.44-1.46, severe mental illness OR 2.34, 95% CI 2.28-2.39). History of anxiety/depression (OR 1.87, 95% CI 1.85-1.90) or severe mental illness (OR 2.86, 95% CI 2.77-2.94) was also associated with higher odds of 30-day readmission. Additionally, individuals with mental illness had a higher prevalence of suicidal ideation within the first year after surgery (no mental illness: 1.88 per 100,000 individuals; anxiety/depression: 51.3 per 100,000 individuals; severe mental illness: 238.9 per 100,000 individuals). Three in 10 Medicare beneficiaries had a preexisting mental illness diagnosis, which was strongly associated with worse postoperative outcomes, as well as suicide risk. Surgeons need to optimize mental health assessment and services in the preoperative setting to improve outcomes for this vulnerable population.

Comparison of the Stopping Opioids after Surgery (SOS) score to preoperative morphine milligram equivalents (MME) for prediction of opioid prescribing after lumbar spine surgery

BACKGROUND CONTEXTReliable estimation of the likelihood for prolonged postoperative opioid use may aid targeted interventions for high-risk patients. Previous studies have recommended differing methodologies for prediction of sustained postoperative opioid use. PURPOSETo compare the performance of the Stopping Opioids after Surgery (SOS) score and preoperative morphine milligram equivalents (MME) for postoperative opioid prescription exposure in a contemporary cohort of lumbar surgery patients. PATIENT SAMPLEAdult patients undergoing posterior decompression with or without fusion for degenerative lumbar conditions between January 31, 2016 and May 31, 2019. STUDY DESIGN/SETTINGRetrospective review at two academic medical centers and three community hospitals. OUTCOME MEASURESThe primary outcome was sustained postoperative prescription opioid exposure at 3 months and 6 months. Reoperations and readmissions were considered secondarily. METHODSThe Stopping Opioids after Surgery score and MME were assigned to patients based on data from their preoperative surgical evaluation. Performance for both measures was assessed for all outcomes by discrimination, including c-statistic and receiver-operating curve analysis. Calibration of the low, medium and high-risk strata with the observed rates of postoperative adverse events were examined. RESULTSOverall, 4,165 patients were included in this study. Preoperative prevalence of prescription opioid use was 31%. Rates of postoperative opioid prescriptions at 3 months and 6 months, were 3.3% (n=136) and 1.5% (n=61). The c-statistics of preoperative oral MME and SOS score for 3-month sustained opioid prescriptions were 0.64 and 0.78, respectively. The c-statistics of preoperative oral MME and SOS score for 6-month sustained opioid prescriptions were 0.64 and 0.82, respectively. C-statistics of preoperative oral MME and SOS score were much lower for reoperation and readmission, although SOS score outperformed MME for both outcomes. CONCLUSIONSThe SOS score clinically outperformed oral MME as a predictive measure for outcomes following lumbar spine surgery. The SOS score may be valuable for identifying individuals at high-risk for sustained prescription opioid use and associated adverse events following spine surgery.

Using a Finite Element Pediatric Hip Model in Clinical Evaluation - A Feasibility Study

The paper describe a method to construct a finite element model of the hip joint of a child based on clinical recorded CT data. A model which can be used for diagnostic aid and pre-operative surgical evaluation. First part of this development is a feasibility study of this method. A scan of the asymptomatic left hip of a 10-year-old girl with a dysplastic right hip was used. Cartilage was not visible why it was modeled as an interaction with constant thickness between two surfaces. For every point on the acetabular and femoral bone surfaces, the shortest distance to the other surface was used to calculate the resulting stress in the normal direction. At a load of 233% BW the model predicted peak pressures in the hip joint of 9.7-13.8 MPa and an area in contact of 351-405 mm2 . Experimental validation using the hip joint of a child was not ethical viable. Instead, our results were compared to previous published experimental studies and computational models investigating the adult hip joint. Good correlation between the current model and previous models were found. The current case specific modeling technique may be a useful complement to the previously developed hip models.

Complication avoidance with pre-operative screening: insights from the Seattle spine team.

Complication rates for complex adult lumbar scoliosis surgery are unacceptably high. Standardized preoperative evaluation protocols have been shown to significantly reduce the likelihood of a spectrum of negative outcomes associated with complex adult lumbar scoliosis surgery. To increase patient safety and reduce complication risk, an entire medical and surgical team should work together to care for adult lumbar scoliosis patients. This article describes preoperative patient evaluation strategies with a particular focus on adult lumbar scoliosis surgery involving six or more levels of spinal fusion. Domains considered include recent preoperative evaluation literature, predictive risk modeling, the appropriate management of medical conditions, and the composition and activities of a multidisciplinary conference review team. An evidence-based comprehensive systematic preoperative surgical evaluation process is described.

Abstract 20288: Quantification and Z-Score “Normalization” of Regional Myocardial Contractile Data in Ischemic Coronary Artery Disease Patients

Introduction: Left ventricular (LV) regional contractile information is currently limited to subjective interpretation of low-resolution echocardiography. In order to establish a more specific and standardized form of imaging, this study compared strain patterns in normal patients to patients with coronary artery disease (CAD) using high-resolution contractile data from cardiac MRI. Methods: Sixty normal test subjects underwent cardiac MRI with multiple 3D strain parameters calculated from tissue tag-plane displacement data. 15,300 LV grid points contributed to a normal human strain database. Sixty patients with known CAD underwent cardiac MRI. Normalized z-scores for 3 strain parameters at each of the LV grid-points were calculated by comparing raw strain values to the normal database. The z-scores at each point were then averaged to generate 15,300 normalized strain z-scores. Clinical evidence for prior ischemic events was sought in each patient’s medical record. Results: Multi-parametric strain information was successfully obtained in all 60 CAD patients with post-processing display of “quantified” regional ischemic injury over patient-specific LV geometry. We displayed “normalized” micro-regional contractile function by intuitive z-score color-coding of regions (&lt;1 standard deviation=blue; 1-2=yellow; &gt;2=red) over patient-specific 3D LV geometry (Figure). Clinical evidence for prior ischemic events obtained from echo, viability studies, ECG, and left heart catherization correlated well with regional injury patterns. Conclusions: The quantitative “normalization” of raw patient-specific values by z-score calculation from a normal human strain database can effectively create vivid displays of prior ischemic events. These high-resolution images provide detailed contractile information that may shape a new paradigm in preoperative surgical evaluation prior to revascularization.

Paediatric spinal fusion surgery and the transition to home-based care: provider expectations and carer experiences

There are more than 12million children with special healthcare needs (CSHCNs) in the United States, many of whom require specialised health-care to treat chronic physical and developmental conditions. This study is a qualitative investigation of programme, surgical and at-home recovery experiences among CSHCNs and their family carers who participated in a spine surgical care programme at a paediatric hospital in the Western United States. The programme is designed to manage increased surgical risk and the transition of care from hospital to home for children with severe scoliosis undergoing spinal fusion surgery. We conducted 30 semi-structured in-depth interviews with 14 surgical team members and 16 family carers of children who had programme evaluations and spinal surgeries in 2006. Data were collected in 2008 and 2009 in hospital or at home locations to gather programme participation feedback from families and inform the adequacy of programme support to families during at-home recovery. Data were analysed by reflexive team and content analysis methodologies. Results showed the programme was effective at improving preoperative surgical evaluation and helping families to anticipate some aspects of the surgical experience and hospital discharge. However, the impact of spinal fusion surgery and the subsequent transition to home-based care was profoundly emotional for patients and their carers. Our data indicate that programme providers underestimated the extent of emotional trauma experienced by patients and families, particularly during the at-home recovery process. The data also suggest meaningful differences in providers' and carers' expectations for surgery. Carers' disappointment with their recovery experiences and the perceived lack of post-discharge support impacted their interpretations of and perspectives on their surgical experience. Implications of this research for surgical care programmes include the need for assessment and provision of support for physical, social, and emotional burdens experienced by patients and carers at pre-surgical, surgical and at-home recovery phases.

Vagal nerve stimulation for the treatment of medically refractory epilepsy: a review of the current literature

The authors conducted a study to evaluate the published results of vagal nerve stimulation (VNS) for medically refractory seizures according to evidence-based criteria. The authors performed a review of available literature published between 1980 and 2010. Inclusion criteria for articles included more than 10 patients evaluated, average follow-up of 1 or more years, inclusion of medically refractory epilepsy, and consistent preoperative surgical evaluation. Articles were divided into 4 classes of evidence according to criteria established by the American Academy of Neurology. A total of 70 publications were reviewed, of which 20 were selected for review based on inclusion and exclusion criteria. There were 2 articles that provided Class I evidence, 7 that met criteria for Class II evidence, and 11 that provided Class III evidence. The majority of evidence supports VNS usage in partial epilepsy with a seizure reduction of 50% or more in the majority of cases and freedom from seizure in 6%-27% of patients who responded to stimulation. High stimulation with a gradual increase in VNS stimulation over the first 6 weeks to 3 months postoperatively is well supported by Class I and II data. Predictors of positive response included absence of bilateral interictal epileptiform activity and cortical malformations. Vagal nerve stimulation is a safe and effective alternative for adult and pediatric populations with epilepsy refractory to medical and other surgical management.

Preoperative assessment and optimization in periampullary and pancreatic cancer

Perioperative management of pancreatic and periampullary cancer poses a considerable challenge to the pancreatic surgeon, anesthesiologist, and the intensive care team. The preoperative surgical evaluation of a pancreatic lesion aims to define the nature of the lesion (malignant or benign), stage the tumor, and to determine resectability or other non-surgical treatment options. Patients are often elderly and may have significant comorbidities and malnutrition. Obstructive jaundice may lead to coagulopathy, infection, renal dysfunction, and adverse outcomes. Routine preoperative biliary drainage can result in higher complication rates, and metal stents may be preferred over plastic stents in selected patients with resectable disease. Judicious use of antibiotics and maintaining fluid volume preoperatively can reduce the incidence of infection and renal dysfunction, respectively. Perioperative fluid therapy with hemodynamic optimization using minimally invasive monitoring may help improve outcomes. Careful patient selection, appropriate preoperative evaluation and optimization can greatly contribute to a favorable outcome after major pancreatic resections.

Preoperative and Intraoperative Sonographic Visibility of Collagen-Based Breast Biopsy Marker Clips

The aim of this study was to determine the sonographic visibility of implanted collagen-based breast biopsy marker clips in the clinic and operating room. Female patients aged > or =18 years who presented for preoperative surgical evaluation within 4 weeks of ultrasound-guided breast biopsy and collagen-based marker clip placement were eligible for this pilot study. The sonographic visibility of the marker clips was rated from 1 (not visible) to 5 (clearly visible) by surgeons at the preoperative appointment, by radiologists at wire localization, and by surgeons in the operating room. Visibility was considered inadequate for values of 1 or 2 and adequate for values of 3, 4, or 5. The data were compared using Wilcoxon's signed-rank test for paired differences across physician (radiologist vs surgeon), time (preoperative visit vs day of surgery), and target (lesion vs clip). Twenty-five patients with 26 lesions were enrolled, and 19 patients returned for all imaging procedures. The mean lesion size was 12 mm (range, 5-24 mm). Adequate marker clip visibility assessed by the surgeons decreased from 80% (20 of 25) at the preoperative appointment to 65% (11 of 17) in the operating room, but the difference was not significant (P=.27). Visibilities of the lesions and clips were similar at the preoperative appointment (P=.61), but the clips were significantly less visible on the day of operation (P=.03). The sonographic visibility of collagen-based marker clips is variable and likely decreases over time but may be adequate to guide intraoperative surgical excision in many cases.

Surgical intervention for thoracic outlet syndrome improves patient's quality of life

To assess long-term quality of life outcomes in patients following transaxillary first-rib resection and scalenectomy for thoracic outlet syndrome (TOS). This was a prospective observational study using the Short-Form 12 (SF-12) and Disability of Arm, Hand, and Shoulder (DASH) instruments between February 2005 and March 2008 in patients with TOS presenting to an academic medical center for preoperative surgical evaluation after failing physical therapy protocol. Surveys were conducted preoperatively and then again at 3, 6, 12, 18, and 24 months after surgery. Longitudinal data analysis was performed with population-averaged models using generalized estimating equations (GEE) method for average rate of recovery. Kaplan-Meier method was used to analyze time to return to work. A total of 70 out of 105 eligible patients (66.7%) completed the study protocol (44 neurogenic; 26 venous), returning 243 valid SF-12 surveys (162 neurogenic; 81 venous) and 188 valid DASH surveys (124 neurogenic; 64 venous). Half (50%) of the neurogenic patients and 77% of the venous patients returned to full-time work or activity within the study follow-up, with half of them doing so by 4 months and 75% of them by 5 months. There was no statistically significant difference in return to work between the neurogenic or venous patients. Neurogenic patients had baseline SF-12 Physical Component Scores (PCS) similar to chronic heart failure patients and were significantly worse than venous patients (33.8 vs 43.6, P < .001). In contrast, no difference existed in Mental Component Scores (MCS) (44.5 vs 43.5, P = .78). In follow-up, on average, PCS scores for neurogenic patients improved 0.24 points (P < .001) and MCS scores improved 0.15 points per month (P = .01); while PCS scores for venous patients improved 0.40 points (P = .004) and MCS scores improved 0.55 points per month (P < .001). Additionally, neurogenic patients had baseline DASH scores that were similar to patients with rotator cuff tears, and they were also significantly worse than venous patients (50.2 vs 25.0, P < .001). DASH scores, on average, also improved 0.85 points (P < .001) for neurogenic patients and 0.81 points (P < .001) for venous patients per month. The use of the SF-12 and DASH instruments in patients with TOS demonstrated significant improvement in patients postoperatively. Venous TOS patients typically improved both physical and mental scores in shorter periods of time than their neurogenic counterparts. Neurogenic and venous TOS patients returned to full-time work/activity within the same length of time postoperatively. However, neurogenic patients required more secondary interventions. We conclude that in appropriately selected patients with either neurogenic or venous TOS, surgical intervention can improve their quality of life over time.

Displasia cortical focal y epilepsia farmacorresistente. Tratamiento con cirugía

Focal cortical dysplasia (FCD) is an unusual cause of refractory epilepsy, in which the morbid anatomy is characterized by cortical laminar dysplasia and the presence of balloon like cells. A 36 year old woman who had had drug-resistant epilepsy since the age of 9 years old, with daily complex partial seizures and seizures in which she fell to the ground. After many therapeutic trials, at the age of 29 years she had a callostomy as palliative treatment for the seizures in which she fell and was completely cured of these. The complex partial seizures increased in frequency, in spite of high doses of multiple drugs, so the possibility of resective surgery was considered. A surface EEG with predominant lateralization and localization to the left temporal lobe, ictal and interictal cerebral SPECT, PET and MR were done. The findings were comparable with two foci of dysplasia in the left cerebral hemisphere, one superior parietal and the other posterior basal temporal in situation. Finally, video-EEG monitoring with foramen ovale electrodes showed ictal activity starting in the left posterior temporal regions and with rapid homolateral anteromesial diffusion. A left temporal lobectomy and amigdalohippocampectomy was done with resection of a posterior basal temporal lesion. This reduced the number of seizures by 90%, with minimal dysnomy as a sequel. The findings on morbid anatomical study were compatible with a FCD. FCD is a cause of refractory epilepsy which may benefit from surgical treatment, with excellent results, after suitable pre-operative surgical evaluation and planning, including hippocampal evaluation since there is a high incidence of associated mesial sclerosis.