Laparoscopic conversion of omega loop gastric bypass to Roux-en-Y gastric bypass for Barrett's esophagus: case report.

BACKGROUND: The number of mini gastric bypass / one anastomosis bypass (MGB-OAGB) procedures in bariatric patients that have been performed world-wide has drastically increased during the past decade. Nevertheless, due to the risk of subsequent biliary reflux and development of ulcer and neoplastic (pre)lesions caused by long-time bile exposure, the procedure is still controversially discussed. In here presented case report, we could endoscopically demonstrate a transformation from reflux oesophagitis to Barrett's metaplasia most likely caused by bile reflux after mini-gastric bypass. To our knowledge, this is a first case study that shows development of Barrett's metaplasia after MGB-OAGB. CASE PRESENTATION: We present the case of a 50-year-old female which received a mini-gastric bypass due to morbid obesity (body mass index (BMI) 42.4 kg/m2). Because of history gastroesophageal reflux disease (GERD), a fundoplication had been performed earlier. Preoperative gastroscopy showed reflux esophagitis (Los Angeles classification grade B) with no signs of Barrett's metaplasia. Three months post mini-gastric bypass, the patient complained about severe bile reflux under 40 mg pantoprazole daily. Six months postoperative, Endoscopically Barrett's epithelium was detected and histopathologically confirmed (C1M0 after Prague classification). A conversion into Roux-en-Y gastric bypass was performed. The postoperative course was without complications. In a follow up after 6 months the patient denied reflux and showed no signs of malnutrition. CONCLUSIONS: The rapid progress from inflammatory changes of the distal esophagus towards Barrett's metaplasia under bile reflux in our case is most likely a result of previous reflux disease. Nevertheless, bile reflux appears to be a potential decisive factor. Study results regarding presence of bile reflux or development of endoscopically de-novo findings after MGB-OAGB are widely non-conclusive. Long-term prospective studies with regular endoscopic surveillance independent of clinical symptoms are needed.

Determination of the transection margin during colorectal resection with hyperspectral imaging (HSI).

PURPOSE: This study evaluated the use of hyperspectral imaging for the determination of the resection margin during colorectal resections instead of clinical macroscopic assessment. METHODS: The used hyperspectral camera is able to record light spectra from 500 to 1000 nm and provides information about physiologic parameters of the recorded tissue area intraoperatively (e.g., tissue oxygenation and perfusion). We performed an open-label, single-arm, and non-randomized intervention clinical trial to compare clinical assessment and hyperspectral measurement to define the resection margin in 24 patients before and after separation of the marginal artery over 15 min; HSI was performed each minute to assess the parameters mentioned above. RESULTS: The false color images calculated from the hyperspectral data visualized the margin of perfusion in 20 out of 24 patients precisely. In the other four patients, the perfusion difference could be displayed with additional evaluation software. In all cases, there was a deviation between the transection line planed by the surgeon and the border line visualized by HSI (median 1 mm; range - 13 to 13 mm). Tissue perfusion dropped up to 12% within the first 10 mm distal to the border line. Therefore, the resection area was corrected proximally in five cases due to HSI record. The biggest drop in perfusion took place in less than 2 min after devascularization. CONCLUSION: Determination of the resection margin by HSI provides the surgeon with an objective decision aid for assessment of the best possible perfusion and ideal anastomotic area in colorectal surgery.

Achalasia-an unnecessary long way to diagnosis.

Although achalasia presents with typical symptoms such as dysphagia, regurgitation, weight loss, and atypical chest pain, the time until first diagnosis often takes years and is frustrating for patients and nevertheless associated with high costs for the healthcare system. A total of 563 patients were interviewed with confirmed diagnosis of achalasia regarding their symptoms leading to diagnosis along with past clinical examinations and treatments. Included were patients who had undergone their medical investigations in Germany. Overall, 527 study subjects were included (male 46%, female 54%, mean age at time of interview 51 ± 14.8 years). Dysphagia was present in 86.7%, regurgitation in 82.9%, atypical chest pain in 79%, and weight loss in 58% of patients before diagnosis. On average, it took 25 months (Interquartile Range (IQR) 9-65) until confirmation of correct diagnosis of achalasia. Though, diagnosis was confirmed significantly quicker (35 months IQR 9-89 vs. 20 months IQR 8-53; p < 0.01) in the past 15 years. The majority (72.1%) was transferred to three or more specialists. Almost each patient underwent at least one esophagogastroduodenoscopy (94.2%) and one radiological assessment (89.3%). However, esophageal manometry was performed in 70.4% of patients only. The severity of symptoms was independent with regard to duration until first diagnosis (Eckardt score 7.14 ± 2.64 within 12 months vs. 7.29 ± 2.61 longer than 12 months; P = 0.544). Fifty-five percent of the patients primarily underwent endoscopic dilatation and 37% a surgical myotomy. Endoscopic dilatation was realized significantly faster compared to esophageal myotomy (1 month IQR 0-4 vs. 3 months IQR 1-11; p < 0.001). Although diagnosis of achalasia was significantly faster in the past 15 years, it still takes almost 2 years until the correct diagnosis of achalasia is confirmed. Alarming is the fact that although esophageal manometry is known as the gold standard to differentiate primary motility disorders, only three out of four patients had undergone this diagnostic pathway during their diagnostic work-up. Better education of medical professionals and broader utilization of highly sensitive diagnostic tools, such as high-resolution manometry, are strictly necessary in order to correctly diagnose affected patients and to offer therapy faster.

Neurostimulation for Parkinson's disease with early motor complications.

BACKGROUND: Subthalamic stimulation reduces motor disability and improves quality of life in patients with advanced Parkinson's disease who have severe levodopa-induced motor complications. We hypothesized that neurostimulation would be beneficial at an earlier stage of Parkinson's disease. METHODS: In this 2-year trial, we randomly assigned 251 patients with Parkinson's disease and early motor complications (mean age, 52 years; mean duration of disease, 7.5 years) to undergo neurostimulation plus medical therapy or medical therapy alone. The primary end point was quality of life, as assessed with the use of the Parkinson's Disease Questionnaire (PDQ-39) summary index (with scores ranging from 0 to 100 and higher scores indicating worse function). Major secondary outcomes included parkinsonian motor disability, activities of daily living, levodopa-induced motor complications (as assessed with the use of the Unified Parkinson's Disease Rating Scale, parts III, II, and IV, respectively), and time with good mobility and no dyskinesia. RESULTS: For the primary outcome of quality of life, the mean score for the neurostimulation group improved by 7.8 points, and that for the medical-therapy group worsened by 0.2 points (between-group difference in mean change from baseline to 2 years, 8.0 points; P=0.002). Neurostimulation was superior to medical therapy with respect to motor disability (P<0.001), activities of daily living (P<0.001), levodopa-induced motor complications (P<0.001), and time with good mobility and no dyskinesia (P=0.01). Serious adverse events occurred in 54.8% of the patients in the neurostimulation group and in 44.1% of those in the medical-therapy group. Serious adverse events related to surgical implantation or the neurostimulation device occurred in 17.7% of patients. An expert panel confirmed that medical therapy was consistent with practice guidelines for 96.8% of the patients in the neurostimulation group and for 94.5% of those in the medical-therapy group. CONCLUSIONS: Subthalamic stimulation was superior to medical therapy in patients with Parkinson's disease and early motor complications. (Funded by the German Ministry of Research and others; EARLYSTIM ClinicalTrials.gov number, NCT00354133.).

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) in patients with peritoneal surface malignancies (PSM): a prospective single-center registry study.

PURPOSE: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new, palliative approach for patients with peritoneal surface malignancies (PSMs). Its main goals are to control symptoms and ascites. For this experimental procedure, treatment efficacy and patient safety need to be closely monitored. METHODS: We performed a prospective registry study for patients with PSMs. Cisplatin (C) (7.5 mg/m2 body surface) and doxorubicin (D) (1.5 mg/m2) were administered laparoscopically via PIPAC. RESULTS: Between November 2015 and June 2020, we recorded data from 108 patients and 230 scheduled procedures. Tumor burden, patient fitness, quality of life, operating time and in-hospital stay remained stable over consecutive procedures. We recorded 21 non-access situations and 14 intraoperative complications (11 intestinal injuries, and three aspirations while inducing anesthesia). Three or more previous abdominal surgeries or cytoreductive surgery (CRS) with intraperitoneal hyperthermic chemoperfusion (HIPEC) were risk factors for non-access and intestinal injuries (χ2, p ≤ 0.01). Five Grade IV and three Grade V postoperative complications according to the Clavien-Dindo Classification (CDC) occurred. Median overall survival was 264 days (interquartile range 108-586). Therapies were primarily discontinued because of death (34%), progressive (26%), or regressive (16%) disease. CONCLUSION: PIPAC is effective in stabilizing PSMs and retaining quality of life in selected patients. Earlier abdominal surgeries and CRS with HIPEC should be considered when determining the indication for PIPAC. Randomized controlled studies are needed to evaluate PIPAC's therapeutic benefits compared to systemic chemotherapy (sCHT) alone. TRIAL REGISTRATION: NCT03100708 (April 2017).

Bariatric surgery in liver cirrhosis.

Introduction: Obesity is frequently associated with its hepatic manifestation, the nonalcoholic fatty liver disease (NAFLD). The most effective treatment for morbid obesity is bariatric surgery (BS) also improving NAFLD and liver function. In patients where NAFLD has already progressed to liver cirrhosis, BS can be considered a high-risk procedure. Hence, consideration of the procedure and the most appropriate timing is crucial. Material and Methods: Obese patients suffering from NAFLD who underwent BS from two German University Medical Centers were retrospectively analyzed. Results: Twenty-seven patients underwent BS. Most common procedures were laparoscopic Roux-en-Y-gastric (RYGB) and laparoscopic sleeve gastrectomy (SG). All patients suffered from liver cirrhosis Child A. A preoperative transjugular portosystemic shunt (TIPS) was established in three patients and failed in another patient. Postoperative complications consisted of wound healing disorders (n = 2), anastomotic bleeding (n = 1), and leak from the staple line (n = 1). This patient suffered from intraoperatively detected macroscopic liver cirrhosis. Excess weight loss was 73% and 85% after 1 and 2 years, respectively. Two patients suffered from postoperative aggravation of their liver function, resulting in a higher Child-Pugh score, while three could be removed from the waiting list for a liver transplantation. Conclusion: BS leads to weight loss, both after SG and RYGB, and potential improvement of liver function in liver cirrhosis. These patients need to be considered with care when evaluated for BS. Preoperative TIPS implantation may reduce the perioperative risk in selected patients.

[Possibilities and perspectives of hyperspectral imaging in visceral surgery]. / Möglichkeiten und Perspektiven der Hyperspektralbildgebung in der Viszeralchirurgie.

HyperSpectral Imaging (HSI) technology enables quantitative tissue analyses beyond the limitations of the human eye. Thus, it serves as a new diagnostic tool for optical properties of diverse tissues. In contrast to other intraoperative imaging methods, HSI is contactless, noninvasive, and the administration of a contrast medium is not necessary. The duration of measurements takes only a few seconds and the surgical procedure is only marginally disturbed. Preliminary HSI applications in visceral surgery are promising with the potential of optimized outcomes. Current concepts, possibilities and new perspectives regarding HSI technology together with its limitations are discussed in this article.

[Preconditioning prior to visceral oncological surgery : A paradigm shift in visceral surgery?] / Präkonditionierung vor viszeralonkologischen Operationen : Ein Paradigmenwechsel in der Viszeralchirurgie?

BACKGROUND: Postoperative complications after complex visceral oncological surgery can lead to substantial impairment of patients. In addition, preoperative physical performance and the severity of postoperative complications determine the long-term recovery process of physical function. Therefore, preconditioning in the preoperative period should be an important part of the preoperative/neoadjuvant treatment. OBJECTIVE: The aim of this article is a critical appraisal of current concepts of prehabilitation as well as their development potential and applicability in visceral surgery. MATERIAL AND METHODS: Based on a selective literature review, current studies and implemented concepts are presented and therapy algorithms are provided. RESULTS: This study differs in primary outcome, design and temporal framework of the intervention. The study results showed positive effects of an active increase in physical fitness in the preoperative period with respect to the quality of life, convalescence and postoperative pulmonary complication rate. DISCUSSION: In addition to the assessment of the individual risk of complications by means of spiroergometry, a targeted nutrition and exercise program can increase the individual performance level prior to visceral surgery and, thus, influence the postoperative risk of complications. The performance should be understood as a modifiable risk factor, which can also be positively influenced in the preoperative phase, even in a short time period. Individual preoperative care optimizes the physical and psychological situation of patients. To ensure the required individual care, approaches must be created and pursued, which can be implemented in a decentralized way.

[Special situations of preconditioning and prehabilitation in oncological visceral surgery]. / Spezialsituationen der Präkonditionierung und Prähabilitation in der onkologischen Viszeralchirurgie.

BACKGROUND: Prehabilitation prior to complex visceral oncological surgery is playing an increasingly important role. OBJECTIVE: The aim of this review article is to present special situations of preconditioning in visceral oncological patient cohorts. The following conditions were defined as special situations with subsequently increased risk profile: cardiopulmonary comorbidities, geriatric patients, neoadjuvant therapy and simultaneous fatigue. MATERIAL AND METHODS: A selective literature review based on a search in the electronic databases MEDLINE, PubMed, Cochrane Library and the International Standard Randomization Controlled Trial Number (ISRCTN) was performed. RESULTS: The identification of high-risk patients is an essential part of the preoperative evaluation conducted by the anesthesiologist prior to surgery. The cardiovascular and the pulmonary risk profile are determined by means of prediction indices evaluating patient-specific and surgery-related risk factors. The increased use of new oral anticoagulants and dual platelet aggregation inhibition requires individualized treatment strategies. Numerous studies have shown clinically relevant effects of exercise therapy interventions throughout all phases of oncological treatment. In addition to positive effects on therapy-associated side effects, sport can also counteract the effects of sedentary behavior in cancer patients and improve the health-related quality of life. The effectiveness of sport and exercise therapies as well as psychological interventions in oncological patients with fatigue (CRF) is broad, with important components being motivation and compliance. DISCUSSION: In high-risk patients an interdisciplinary approach to planning and conduction of prehabilitation is essential for the early detection and optimization of perioperative risk factors and potential complications. The aim is faster recovery, reduced morbidity and mortality and the possibility to improve long-term survival and quality of life.

[Economic aspects of oncological esophageal surgery : Centralization is essential]. / Ökonomische Aspekte der onkologischen Ösophaguschirurgie : Zentralisierung ist essenziell.

The incidence of esophageal carcinoma has increased in recent years in Germany. The aim of this article is a discussion of the economic aspects of oncological esophageal surgery within the German diagnosis-related groups (DRG) system focusing on the association between minimum caseload requirements and outcome quality as well as costs. The margins for the DRG classification G03A are low and quickly exhausted if complications determine the postoperative course. A current study using nationwide German hospital discharge data proved a significant difference in hospital mortality between clinics with and without achieving the minimum caseload requirements for esophagectomy. Data from the USA clearly showed that besides patient-relevant parameters, the caseload of a surgeon is relevant for the cost of treatment. Such cost-related analyses do not exist in Germany at present. Scientific validation of reliable minimum caseload numbers for oncological esophagectomy is desirable in the future.

Remote memory in patients with acute brain injuries.

Remote memory was investigated in an unselected sample of 26 patients with either unilateral tumours in the temporal lobes or traumatic brain injuries. Six patients underwent excisions within the left temporal lobe, and nine patients were operated on within the right temporal lobe. In both groups, patients with excisions including and sparing the hippocampal formation were studied. Their performance was compared to that of 11 patients with moderate to severe head trauma and to a normative sample of 214 healthy controls. Remote memory was assessed using a famous events test with items of extremely low salience that had been proven to be of low difficulty for those old enough at the time of the event's actuality. The results show severely disturbed retrograde memory functions in the left temporal tumour group. These patients achieved similar scores to patients with severe traumatic brain injury. Right hemispheric patients showed a pattern of results comparable to that of healthy controls. The strongest effects were in the free recall part of the test. In most of the patients, no graded memory loss was observable. No consistent association to recent memory function could be identified. Since most of the remote memory test items used denoted famous names which were cued by rich semantic information, the type of deficit seen may be best understood in terms of a specific dysfunction of the semantic stores containing information about famous proper names.

Classification system based on kinematic MR imaging in cervical spondylitic myelopathy.

BACKGROUND AND PURPOSE: Functional myelographic studies are often used to evaluate the dynamic changes of the cervical spinal canal during flexion and extension. The purposes of this study were to use kinematic MR imaging to assess the dynamic changes of the cervical spine in patients at different stages of degenerative disease and to describe a classification system based on static and dynamic factors in the pathogenesis of cervical spondylitic myelopathy. METHODS: Eighty-one patients with different stages (I-IV) of degenerative disease of the cervical spine were examined with MR imaging. In the neutral position (0 degrees) and at maximum flexion and extension, spinal stenosis was classified for each segment according to the following grading system: 0 = normal, 1 = partial obliteration of the anterior or posterior subarachnoid space, 2 = complete obliteration of the anterior or posterior subarachnoid space, and 3 = cervical cord compression or displacement. RESULTS: At flexion and extension, the prevalence of spinal stenosis and cervical cord impingement increased as the stage of degenerative disease progressed. With regard to a pincer effect (anterior and posterior cord impingement) and cord encroachment at multiple segments, statistically significant differences were observed at stages III and IV as compared with stages I and II. Significant increase in cord impingement was seen in 22 (27%) of 81 patients at extension, as compared with four (5%) of 81 patients at flexion. CONCLUSION: Regardless of the stage of degenerative disease and grade of spinal stenosis at the neutral position (0 degrees), cervical spinal motion may contribute to the development of cervical spondylitic myelopathy.

Chronic reversible cerebral ischemia: evaluation of a new baboon model.

The authors describe their experience with a baboon model of reversible cerebral ischemia. Middle cerebral artery occlusion was achieved by external compression with an implantable, inflatable balloon cuff in awake, unanesthetized baboons. Selective cerebral angiography confirmed consistent, reliable occlusion. Computed tomography demonstrated early density changes after ischemia, which were reversible with reperfusion. Neurological evaluation demonstrated a "recruitment response" of increasingly persistent deficit with repeated occlusion. Permanent deficits were noted after extensive angiography during periods of occlusion. This was accompanied by the dropout of small vessels in the middle cerebral artery distribution. The results of pathological examinations were consistent with the clinical examinations. No gross or microscopic changes were noted after repeated occlusions that caused deficits like those of transient ischemic attacks. Consistent infarctions were noted in animals with permanent deficits after permanent occlusion or after repeated occlusion and extensive angiography.

Analysis of gait in cervical myelopathy.

Gait disorders are a frequent symptom of cervical spondylotic myelopathy (CSM). Twelve patients with CSM underwent gait analysis before and after decompressive surgery. They were assessed on a walkway and a treadmill and compared with a healthy matched control group. The following features were observed in the CSM group before surgery: significantly reduced gait velocity and step length (P<0. 05), prolonged double support, increased step width, and reduced ankle joint extension during treadmill walking. Knee and hip kinematics did not differ from controls. Two months after surgery, spatio-temporal parameters had moved towards normal values, velocity, step length and cadence had increased significantly, and there was reduction of step width during treadmill walking, indicating improved equilibrium. Gait analysis is an objective tool to document functional recovery after decompressive surgery in CSM.

[Uptake of DL-3-123I-iodo-alpha-methyltyrosine in recurrent brain tumors]. / Anreicherung von DL-3-123I-Jod-alpha-methyltyrosin in Hirntumorrezidiven.

DL-3-123I-iodo-alpha-methyltyrosine (123I-IMT) is a radiopharmacon which concentrates in brain tumors and can be employed in SPECT. We performed 20 studies in 16 patients after neurosurgery for malignant brain tumors (localization of the primary tumor by CT/MRI). Tumor/non-tumor ratios (T/NT) were calculated in ROI-technique. In 17 cases there was a recurrence or tumor remnant. 14/17 were detectable by increased uptake (T/NT 1.43-2.25). The scans were correlated with CT/MRI studies and validated by biopsy (6/14) or follow-up. All 3 patients without recurrence (neuroradiological follow-up over 6-24 months) had a negative scan. 123I-IMT scintigraphy provides complementary information to CT and MRI. In equivocal neuroradiological or clinical cases it may be valuable in the detection of tumor recurrences and allows an earlier onset of therapy.

Children's spatial behavior is differentially affected after traumatic brain injury.

Spatial behavior in 20 children with severe traumatic brain injury (TBI) and 20 healthy controls was investigated using the Kiel Locomotor Maze. Children had to remember defined locations in an experimental chamber with completely controlled intra- and extra-maze cues until learning criterion was reached. In a second experiment, spatial orientation strategies were assessed. Children with TBI were shown to be impaired in spatial learning and spatial memory. Spatial orientation was found to be deficient even in cases where spatial learning and memory proved to be unimpaired, especially in tasks that demanded the use of relational place strategies. Children who suffered a TBI at an early age proved to be more severely impaired in spatial learning and orientation than older children.

Development of spatial memory and spatial orientation in preschoolers and primary school children.

The present study addresses the question of what kind of information children use when orientating in new environments, if given proximal and distal landmarks, and how spatial memory develops in the investigated age groups. Ten 5-year-old, ten 7-year-old and ten 10-year-old children were presented with the 'Kiel Locomotor Maze', containing features of the Radial Arm Maze and the Morris Water Maze, in order to assess spatial memory and orientation. Children had to learn to approach baited locations only. Task difficulty was equated with respect to the children's age. Training was given until the children reached criterion. During testing, the maze configuration and response requirements were systematically altered, including response rotation, cue rotation, cue deletion and response rotation with cue deletion in order to assess the spatial strategies used by the children. During training and testing, working-memory errors (WM), reference-memory errors (RM) and working-reference memory errors (WR) were recorded. As expected, no difference between age groups appeared during training, thus confirming comparable task difficulty across age groups. During testing, age groups differed significantly with regard to the orientation strategy used. The 5-year-olds were bound to a cue strategy, orientating towards local, proximal cues. The 10-year-olds mastered all tasks, thus displaying a place strategy, being able to use distal cues for orientation, and were even able to do so after being rotated 180 degrees. The 7-year-olds proved to be at an age of transition: five of them were bound to a cue strategy, five children were able to adopt a place strategy. The differences in the orientation strategies used by children of different age groups was reflected by the sum of errors they made, also by RM. WM were found to be rare, especially in older children. We conclude that preschoolers use a cue strategy, that the development of place strategies occurs during primary school age and seems to be complete by the age of 10 years.

Kinematic effects of subthalamic stimulation on reach-to-grasp movements in Parkinson's disease.

BACKGROUND: Parkinsonian patients demonstrate particular difficulties when performing sequential motor tasks compared to simple movements indicating an important role of the basal ganglia in switching between different motor programs. OBJECTIVE: To investigate the impact of subthalamic stimulation on the kinematics of composed reach-to-grasp movements and on isolated movement segments. METHODS: 11 age matched controls and 16 PD patients with subthalamic stimulation were examined without medication with stimulation switched on and off. All subjects were instructed to perform three different externally cued hand movements: 1) The complete reach-to-grasp movement consisting of hand transport to and precision grip around a target. 2) The isolated reach movement to the grip device 3) The isolated precision grip and button press. Kinematic data were recorded with a 3D ultrasound movement analysis system (CMS 70 P4-V5, Zebris, Germany). RESULTS: The effect of subthalamic stimulation was accentuated during the reach phase compared to the grip formation during the composed movement. Stimulation induced kinematic changes of the composed movement were comparable to those of both isolated submovements. CONCLUSION: Subthalamic stimulation improved certain aspects of all three hand movement types but did not differentially impact the composed reach-to-grasp task compared to the simple submovements. We assume that the complete reach-to-grasp task is encoded in a single generalised motor program which is affected by stimulation.

Outcome of craniocerebral gunshot injuries in the civilian population. Prognostic factors and treatment options.

AIM: Gunshot wounds to the head are rare in Europe. They may be inflicted by low-velocity handguns, captive bolt guns and tear gas cartridges and mostly result from suicide attempts. The experience of neurosurgeons with this kind of traumatic injury is decreasing; the aim of this study was therefore to analyse prognostic factors which help to decide whether or not to operate and to discuss treatment options. METHODS: Thirty patients with gunshot head injuries treated in our hospital from 1993 to 2008 were retrospectively evaluated. Glasgow Coma Scale (GCS) score, pupil reactivity, lesion localisation, number of bone fragments, intracranial pressure (ICP), midline shift, hypotension, and dural penetration were analysed for their prognostic value. Surgically and non-surgically treated patients were evaluated separately. Complications were registered. RESULTS: A low GCS of 3-8, fixed pupils, >2 bone fragments, bilobar or posterior fossa/brainstem lesions and ICP >45 mmHg were indicators of a poor prognosis. CONCLUSION: Patients with a GCS of 3-8 and two non-reactive pupils should not be operated. If one or both of the pupils are reactive, surgery should be performed irrespective of the GCS score, except in patients with translobar/transventricular wounds. Even if there are no clear contraindications to surgery, the outcome is expected to be poor in patients with a low GCS score, midline shift >10 mm, >2 bone fragments in the brain, and a bilobar, posterior fossa/brainstem or ventricular lesion and ICP >45 mmHg. When surgery is performed the wound and the missile or bone track should be debrided meticulously, the wound and dura should be closed in a watertight fashion and antibiotic prophylaxis as well as tetanus serum should be given.