Isolated 6th cranial nerve palsy: a rare manifestation of tuberculosis

<p>Tuberculosis (TB) is a contagious infection that is usually caused by <em>Mycobacterium tuberculosis</em> bacteria. It usually affects the lungs and also spreads to the brain and spine. In the central nervous system, the neurological manifestations are numerous and varied and usually occur in two major forms, tuberculous meningitis and tuberculoma. Tuberculoma are well defined, granulomatous, space occupying lesions, which can occur anywhere in the central nervous system. Usually, brainstem tuberculoma can cause sixth and seventh cranial nerve affections along with motor and sensory symptoms, which are usually unilateral. Isolated abducens nerve palsy could be attributed to lesions of the nerve along their extra axial course and cause diplopia. Here we are presenting a case report of an 18-year-old boy with isolated sixth nerve palsy due to tuberculosis. The diagnosis of tuberculosis was achieved using interventional radiology for the purpose of biopsy. Using an image guided technique, we could avoid an open surgical procedure. </p>

Enigmatic Case of Bladder Hematoma Masquerading as Massive Hemoperitoneum in Postpartum Phase: Cystoscopic Management

Significant spontaneous bladder trauma at vaginal birth is rare and affects <1% of deliveries. Bladder contusion resulting in urinary retention 5 days after normal delivery is being described here in a 23-year-old primiparous lady who underwent cystoscopic fulguration of the bleeder. Early diagnosis and prompt treatment can prevent long term, irreversible damage to the detrusor muscle that can have a permanent impact on a woman’s quality of life. A multidisciplinary surgical team comprising gynaecologists, urologists and anaesthetists carried out examination under anaesthesia and cystoscopy. An arterial bleeder below the interureteric ridge in the area of bladder neck was identified and coagulated with Resectoscope loop to secure hemostasis ensuring a safe distance from both ureteric orifices. Postoperative continuous bladder drainage for 3 weeks resulted in complete recovery. Careful evaluation of the stable patient with radiologic imaging and endoscopic management in competent hands should be considered before proceeding with any open surgical procedure in such cases

Embolization strategies for intracranial dural arteriovenous fistulas with an isolated sinus: a single-center experience in 20 patients

BackgroundIntracranial dural arteriovenous fistulas (DAVFs) draining into an isolated sinus segment constitute a specific entity within the spectrum of cranial dural AV shunts, with under-reporting of their optimal treatment.ObjectiveTo describe the multimodal treatment approach to isolated sinus DAVFs in a large single-center cohort.MethodsRetrospective analysis of adult patients with an isolated sinus DAVF treated at our institution between 2004 and 2020 was performed. Cases were analyzed for demographics, clinical presentation, angiographic findings, treatment techniques, angiographic and clinical outcomes, and complications.ResultsOf 317 patients with DAVFs, 20 (6.3%) with an isolated sinus DAVF underwent treatment. Transarterial embolization was performed through the middle meningeal artery in 9 of 12 procedures, with a success rate of 66.7%. Transarterial glue embolization proved successful in two of five procedures (40%) and Onyx in six of seven procedures (85.7%). Transvenous embolization (TVE) with navigation via the occlusion into the isolated sinus was successful in seven out of nine procedures (77.8%). All three open TVE and one pure open surgical procedure gained complete closure of the fistula. There were two major complications. Complete occlusion of the fistula was eventually obtained in all cases (100%).ConclusionsIsolated sinus DAVFs are always aggressive and require a multimodal approach to guarantee closure of the shunt. Transarterial treatment with Onyx achieves good results. Transvenous treatment appears equally successful, navigating into the occluded segment across the occlusion or via burr hole as backup.

Stenting of ruptured gastroduodenal artery pseudoaneurysm

Gastroduodenal artery (GDA) aneurysm is a rare surgical entity that causes various symptoms. In the case of rupture, it usually presents an ominous prognosis and mortality rate of up to 40%. Although open surgical procedure is a mainstay, endovascular intervention is emerging a promising treatment in recent years, due to its advantages and safety. We present a case of upper gastrointestinal bleeding caused by ruptured GDA pseudoaneurysmin a 71-year-old woman, with medical episodes of acute pancreatitis, a pancreatic body tumor removal surgery was performed, and now the tumor is relapsing and metastasizing. The treatment approach is blocking off the pseudoaneurysm by a covered stent. The procedure was successful and the patient is asymptomatic. Two months later, the pseudoaneurysm reduces its size and completely excluded from the preservation of the blood flow in the artery.Follow-up to 26 month, patient is well, no symptoms or recurrence. Endovascular interventional treatment in the case of GDA aneurysms is considered a promising alternative not only to open surgery but also to an effective emerging technique even in the acute setting.

Retrospective analysis of safety and efficacy of enhanced recovery pathways in stage II–III colorectal cancer patients submitted to surgery and adjuvant therapy

Background The American Society of Colon and Rectal Surgeons is suggesting laparoscopic surgeries for colorectal cancer. Conventional perioperative procedures like long preoperative fasting and bowel procedures are not useful and harmful to patients undergoing surgeries for colorectal cancer. The objectives of the study were to compare surgery outcomes, hospital stays, and survival of patients who received fast-track (laparoscopy/open) surgical procedure followed by chemotherapy against those who received conventional (laparoscopy/open) surgical procedure followed by chemotherapy for colorectal cancer. Methods The study analyzes the outcomes of a total of 542 colorectal cancer (preoperative biopsies stage II or III) patients submitted to surgery and adjuvant chemotherapy. The study cohort is retrospectively subdivided in 4 groups submitted to open or laparoscopic resection with or without fast-track protocol appliance and two different chemotherapy regimens. Patients who ended up being TNM stage I have not received the adjuvant chemotherapy. Results The fast-track surgical procedure had shorter total hospital stays and postoperative hospital stays than the conventional surgical procedures. Flatus resumption time, the time until first defecation, and intraoperative blood loss were shorter for the fast-track surgical procedures than the conventional surgical procedures. Those surgery outcomes were also shorter for the fast-track laparoscopy than the open fast-track. Resumption of a fluid diet and ambulation onset time were shorter for the fast-track surgical procedures than the conventional surgical procedures. The surgical checkpoints that were compliance by patient of fast-track surgeries were significantly fewer than those of the conventional surgeries. Clinically significant difference for QLQ-C30/CR38 score after chemotherapy was reported between patients who received open conventional surgeries and those patients who received fast-track laparoscopy (59.63 ± 2.26 score/patient vs. 71.67 ± 5.19 score/patient). There were no significant differences for the number of patients with any grade adverse effects (p = 0.431) or with grade 3–4 adverse effects (p = 0.858), and the disease-free and overall survival among cohorts. Conclusions The fast-track surgical procedure is effective and safe even in a multidisciplinary scenario as colorectal cancer treatment in which surgery is only a part of management. Level of evidence: III Technical efficacy stage: 4.

Improved access in minimally invasive temporomandibular joint surgery through a novel endaural template

Background Digitally designed surgical templates for minimally invasive temporomandibular joint (TMJ) surgery (MITMJS) are a promising tool for improving the safety of these procedures. Given the TMJ anatomy, the template fitting and intraoperative overview are the most important issues for a safe surgery. This article is a technical advance article that aims to describe an endaural surgical template based on the Moses approach as a possible solution in TMJ surgery. Methods Three patients with internal derangement were treated with the guidance of a MITMJS template based on cone beam computed tomography (CBCT) and a surface imprint of the periauricular region. None of the patients needed an additional open surgical procedure. Fitting of the templates was judged in terms of position and rotational stability. Surgical side effects and complications were recorded for each patient. Results The template design and clinical use were satisfactory for MITMJS. The templates showed satisfying fit and good visibility. In the study cohort, no bleeding, facial nerve injury, or other complications occurred after the procedure, and no visible scars were noted postoperatively. Conclusion Our feasibility report on template-guided MITMJS shows a promising new application of templates. It points to improved access in arthroscopy or arthrocentesis of TMJ surgery through endaural access with an increased level of safety during surgery.

Improved access in minimally invasive temporomandibular joint surgery through a novel endaural template.

BackgroundDigitally designed surgical templates for minimally invasive temporomandibular joint (TMJ) surgery (MITMJS) are a promising tool for improving the safety of these procedures. Given the TMJ anatomy, the template fitting and intraoperative overview are the most important issues for a safe surgery. This article is a technical advance article that aims to describe an endaural surgical template based on the Moses approach as a possible solution in TMJ surgery.Methods:Three patients with internal derangement were treated with the guidance of a MITMJS template based on cone beam computed tomography (CBCT) and a surface imprint of the periauricular region. None of the patients needed an additional open surgical procedure. Fitting of the templates was judged in terms of position and rotational stability. Surgical side effects and complications were recorded for each patient.Results:The template design and clinical use were satisfactory for MITMJS. The templates showed satisfying fit and good visibility. In the study cohort, no bleeding, facial nerve injury, or other complications occurred after the procedure, and no visible scars were noted postoperatively.Conclusion:Our feasibility report on template-guided MITMJS shows a promising new application of templates. It points to improved access in arthroscopy or arthrocentesis of TMJ surgery through endaural access with an increased level of safety during surgery.

Outcome after Hybrid Outflow Interventions for Chronic Limb-threatening Ischemia

Background and Aims: Because chronic limb-threatening ischemia (CLTI) is often associated with multilevel arterial disease, it usually requires revascularization at different sites of the limb vasculature. We aim to assess the outcome of the hybrid interventions including open surgical revascularization together with outflow segment percutaneous transluminal angioplasty (PTA) in patients with chronic limb-threatening ischemia. Material and Methods: This study included all hybrid outflow-PTA interventions (n = 80) on patients suffering from CLTI performed in Helsinki University Hospital between 2003 and 2015. Follow-up ended on 31 December 2019. Patient data were prospectively collected into our vascular registry and scrutinized retrospectively. Thirty-one patients (39%) suffered from rest pain (Rutherford category IV) and 49 patients (61%) had ischemic ulcers (Rutherford category V–VI). The most common open surgical procedure was femoral endarterectomy (n = 63, 79%) and the most common endovascular procedure was superficial femoral artery percutaneous transluminal angioplasty (n = 65, 81%). Mean follow-up time was 56 months (range: 4 days–183 months). Results: Limb salvage was at 30 days—92%, at 1 year—91%, and at 5 and 10 years—86%. Survival and amputation-free survival were at 30 days—93% and 86%, at 1 year—80% and 76%, at 5 years—51% and 48%, and at 10 years—21% and 21%. Wound healing at 3, 6, and 12 months was 48%, 71%, and 87%. Freedom from target lesion revascularization was at 30 days—97%, at 1 year—88%, at 5 years—72%, and at 10 years—66%. Conclusion: Hybrid outflow revascularization is an important tool in the vascular surgeon’s armamentarium for treatment of patients with multilevel arterial disease causing chronic limb-threatening ischemia.

Improved Access in Minimally Invasive Temporomandibular Joint Surgery via a Novel Endaural Template

Background:Digitally designed surgical templates for minimally invasive temporomandibular joint (TMJ) surgery (MITMJS) are a promising tool for improving the safety in these procedures. Given the anatomy of the TMJ, the fitting of the template and intraoperative overview are the most important issues to conduct the surgery safely. This article describes an endaural surgical template based on the Moses approach as a possible solution.Methods:Three patients with internal derangement were treated with guidance of a MITMJS- template based on cone beam computed tomography (CBCT) and a surface imprint of the periauraural region. None of the patients needed an additional open surgical procedure. Fitting of the templates was judged in terms of position and rotational stability. Surgical side effects and complications were recorded for each patient.Results:The template design and clinical use performed the MITMJS satisfactory. The templates showed satisfying fit and good visibility. In the study cohort, no bleeding, facial nerve injury, or other complications occurred after the procedure, and no visible scars were noted postoperatively.Conclusion:Our feasibility report on template-guided MITMJS shows a promising new application of templates. It points an improved access in arthroscopy or arthrocentesis of TMJ- surgery via an endaural access with increased level of safety during surgery.

Improved Access in Minimally Invasive Temporomandibular Joint Surgery via A Novel Endaural Template

Background: Digitally designed surgical templates for minimally invasive temporomandibular joint (TMJ) surgery (MITMJS) are a promising tool for improving the safety in these procedures. Given the anatomy of the TMJ, the fitting of the template and intraoperative overview are the most important issues to conduct the surgery safely. This article describes an endaural surgical template based on the Moses approach as a possible solution.Material and Methods: Three patients with internal derangement were treated with guidance of a MITMJS- template based on cone beam computed tomography (CBCT) and a surface imprint of the periauraural region. None of the patients needed an additional open surgical procedure. Fitting of the templates was judged in terms of position and rotational stability. Surgical side effects and complications were recorded for each patient.Results: The template design and clinical use performed the MITMJS satisfactory. The templates showed satisfying fit and good visibility. In the study cohort, no bleeding, facial nerve injury, or other complications occurred after the procedure, and no visible scars were noted postoperatively.Conclusion: Our feasibility report on template-guided MITMJS shows a promising new application of templates. It points an improved access in arthroscopy or arthrocentesis of TMJ- surgery via an endaural access with increased level of safety during surgery.