Impact of Meniscus Repair in Conjunction With Anterior Cruciate Ligament Reconstruction on Functional Outcomes at Six Months.

Background and aim Anterior cruciate ligament (ACL) injuries often occur along with menisci tears. ACL reconstruction with meniscectomy has long been the preferred technique for such injuries; however, it has been postulated to increase the chances of osteoarthritis (OA). Therefore, recent techniques have involved preserving menisci while reconstructing ACL to prevent OA and improve overall functional outcomes. This study aimed to evaluate the functional outcomes of arthroscopic meniscal repair performed concurrently with ACL reconstruction at six months post-surgery. Methodology We conducted a cross-sectional study at a tertiary care center after getting appropriate ethics committee approval. A total of 67 participants who met the inclusion and exclusion criteria were enrolled in the study after obtaining informed consent. Their demographics were recorded retrospectively from hospital records, while their Lysholm Knee Score (LKS) responses were collected prospectively during their sixth-month follow-up visit to our department. Analysis was done using Microsoft Excel. Appropriate statistical tests including chi-square, analysis of variance (ANOVA), and independent t-tests were applied to keep an alpha of 0.05. Results We found that the mean age of participants was 35 years. The mean LKS of patients who underwent isolated ACL reconstruction (ACLR) was 86.02 ± 9.38. For those who underwent ACLR plus meniscus repair (MR), the mean LKS was marginally higher at 87.4 ± 7.41 during their sixth-month follow-up, with a P-value of 0.27. Furthermore, the mean LKS of patients who underwent ACLR plus meniscectomy was 86 ± 10.48. Comparing the means of all three groups revealed no statistical difference among any surgical approach with a P-value of 0.69. A total of 33 (49.25%) participants achieved an LKS falling within the Good category (84-94). Comparing between three surgical groups and their LKS categories also revealed no statistical difference with a P-value of 0.7. Conclusions Short-term functional outcomes in patients undergoing ACLR or ACLR plus MR using patient-reported knee scores like LKS demonstrate favorable outcomes but fail to demonstrate statistical significance. On a longer follow-up period, a reduction in the prevalence of OA is a possibility with the preservation of menisci; however, conflicting evidence in the literature about the approach to ACL injuries with menisci involvement warrants large-scale randomized controlled trials to decide upon the standard of care.

Spontaneous Pneumothorax in a Young Female With Lymphangioleiomyomatosis.

Lymphangioleiomyomatosis (LAM) is a rare disorder of abnormal proliferation of smooth muscle-like cells which results in the formation of thin-walled cysts and progressive lung destruction. It commonly presents with progressive dyspnea that is often associated with a history of pneumothorax or chylothorax particularly among females of reproductive age. In this report, we present a case of hydropneumothorax as the initial presentation of LAM in a 33-year-old woman, a rather rare presentation. We also discuss the pathogenetic mechanisms, the diagnosis, and treatment strategies using mTOR inhibitors like sirolimus.

Complication of Middle Cerebral Artery Aneurysm Surgery: An M2 Tear at the Neck, Managed with a Salvage M2-to-M2 In Situ Bypass.

An unexpected rupture at the aneurysm neck, with or without adjacent arterial injury or compromise of distal branches during microsurgical clipping, can be a challenging surgical problem to resolve. In this presented case of a neurologically intact 65-year-old woman, elective clipping of an unruptured right middle cerebral artery bifurcation aneurysm was complicated by an unexpected M2 tear at the neck, involving the origin of the frontal M2. Attempts to seal the tear directly, using various techniques, failed; therefore, it was ultimately managed with sacrifice of the vessel and a salvage side-to-side M2-to-M2 in situ bypass. Six months after surgery, the patient demonstrated moderate disability but was able to ambulate with a cane.

Variation in Experiences and Attainment in Surgery Between Ethnicities of UK Medical Students and Doctors (ATTAIN): Protocol for a Cross-Sectional Study.

BACKGROUND: The unequal distribution of academic and professional outcomes between different minority groups is a pervasive issue in many fields, including surgery. The implications of differential attainment remain significant, not only for the individuals affected but also for the wider health care system. An inclusive health care system is crucial in meeting the needs of an increasingly diverse patient population, thereby leading to better outcomes. One barrier to diversifying the workforce is the differential attainment in educational outcomes between Black and Minority Ethnic (BME) and White medical students and doctors in the United Kingdom. BME trainees are known to have lower performance rates in medical examinations, including undergraduate and postgraduate exams, Annual Review of Competence Progression, as well as training and consultant job applications. Studies have shown that BME candidates have a higher likelihood of failing both parts of the Membership of the Royal Colleges of Surgeons exams and are 10% less likely to be considered suitable for core surgical training. Several contributing factors have been identified; however, there has been limited evidence investigating surgical training experiences and their relationship to differential attainment. To understand the nature of differential attainment in surgery and to develop effective strategies to address it, it is essential to examine the underlying causes and contributing factors. The Variation in Experiences and Attainment in Surgery Between Ethnicities of UK Medical Students and Doctors (ATTAIN) study aims to describe and compare the factors and outcomes of attainment between different ethnicities of doctors and medical students. OBJECTIVE: The primary aim will be to compare the effect of experiences and perceptions of surgical education of students and doctors of different ethnicities. METHODS: This protocol describes a nationwide cross-sectional study of medical students and nonconsultant grade doctors in the United Kingdom. Participants will complete a web-based questionnaire collecting data on experiences and perceptions of surgical placements as well as self-reported academic attainment data. A comprehensive data collection strategy will be used to collect a representative sample of the population. A set of surrogate markers relevant to surgical training will be used to establish a primary outcome to determine variations in attainment. Regression analyses will be used to identify potential causes for the variation in attainment. RESULTS: Data collected between February 2022 and September 2022 yielded 1603 respondents. Data analysis is yet to be competed. The protocol was approved by the University College London Research Ethics Committee on September 16, 2021 (ethics approval reference 19071/004). The findings will be disseminated through peer-reviewed publications and conference presentations. CONCLUSIONS: Drawing upon the conclusions of this study, we aim to make recommendations on educational policy reforms. Additionally, the creation of a large, comprehensive data set can be used for further research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40545.

Fine needle aspiration cytology of follicular dendritic cell sarcoma of the stomach masquerading as gastrointestinal stromal tumor: A case report of a unique entity with emphasis on cytomorphology.

Follicular dendritic cell sarcoma (FDCS) is a rare malignant neoplasm, postulated to arise from follicular dendritic cells, with approximately 343 reported cases. Less than 100 cases of FDCS were in the gastrointestinal tract, with only four cases described in the stomach, none of them diagnosed on fine needle aspiration (FNA) cytology. We report here the first case of FDCS of the stomach diagnosed on FNA. Our patient is a 31-year-old male who presented with several years history of intermittent abdominal pain prompting occasional emergency-room visits. Imaging showed a 10.6 cm mass arising from the stomach, concerning for gastrointestinal stromal tumor. FNA cytology was performed using five passes with a 22-gauge needle. The smears were moderately cellular consisting of sheets and large, loosely cohesive clusters of ovoid to spindle cells with indistinct cytoplasmic borders and abundant cytoplasm, peppered with numerous small mature lymphocytes. The nuclei of the tumor cells were oval with finely granular chromatin with frequent nuclear grooves, pseudoinclusions, and easily recognizable mitotic figures. The tumor cells were positive for FDCS markers (CD21, CD23, and CD35).

Sporadic hyperplastic polyp associated with above-average risk of developing metachronous colorectal cancer.

Post-colonoscopy surveillance interval for colorectal polyps depends on the size, number, and pathological classification of removed polyps. The risk of sporadic hyperplastic polyps (HPs) for developing colorectal adenocarcinoma remains debatable due to limited data. We aimed to evaluate the risk of metachronous colorectal cancer (CRC) in patients with sporadic HPs. A total of 249 patients with historical HP(s) diagnosed in 2003 were included as the disease group, and 393 patients without any polyp as the control group. All historical HPs were reclassified into SSA or true HP based on the recent 2010 and 2019 World Health Organization (WHO) criteria. Polyp size was measured under light microscope. Patients developed CRC were identified from the Tumor Registry database. Each tumor was tested for DNA mismatch repair proteins (MMR) by immunohistochemistry. Results showed that 21 (8%) and 48 (19%) historical HPs were reclassified as SSAs based on the 2010 and 2019 WHO criteria, respectively. The mean polyp size of SSAs (6.7 mm) was significantly larger than HPs (3.3 mm) (P<0.0001). For polyp size ≥5 mm, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for diagnosing SSA was 90%, 90%, 46%, and 99%, respectively. Left-sided polyps with size <5 mm were 100% of HPs. Five of 249 (2%) patients developed metachronous CRC during the 14-year follow-up from 2003 to 2017, including 2 of 21 (9.5%) patients with SSA diagnosed at intervals of 2.5 and 7 years, and 3 of 228 (1.3%) patients with HP(s) at 7, 10.3, and 11.9 years. Two of 5 cancers showed MMR deficiency with concurrent loss of MLH1/PMS2. Based on the 2019 WHO criteria, the rate of developing metachronous CRC in patients with SSA (P=0.0116) and HP (P=0.0384) was significantly higher than the control group, and no significant difference was observed between patients with SSA and with HP (P=0.241) in this cohort. Patients with either SSA or HP also had higher risk of CRC than average-risk US population (P=0.0002 and 0.0001, respectively). Our data add a new line of evidence that patients with sporadic HP are associated with above-average risk of developing metachronous CRC. Post-polypectomy surveillance for sporadic HP may be adjusted in future practice given the low but increased risk of developing CRC.

Matrix metalloproteinase enzyme responsive delivery of 5-Fluorouracil using Collagen-I peptide functionalized Dendrimer-Gold nanocarrier.

OBJECTIVE: The aim was to develop matrix metalloproteinase 1 (MMP1) responsive nanoparticle system for the delivery of 5-fluorouracil (5Fu) anticancer drug. SIGNIFICANCE: The MMP1 in the cancer microenvironment-induced drug release have the advantage of targeted drug release and reduce the distribution of drug to the healthy tissues. METHOD: G5 poly(amidoamine) (PAMAM) dendrimer (G5)-coated gold nanoparticles (G5AuNP) were synthesized and loaded with 5Fu. The drug-loaded nanoparticles were further coated with collagen I (Col-I) peptide, which is a substrate for MMP1 enzyme (Col-I 5Fu@G5AuNP). RESULT: The nanoparticles were highly monodispersed with a particle size of 30 nm and showed high drug encapsulation efficiency. The release of drug from the nanoparticles in HEPES buffer pH 7.4 was faster, higher and better controlled when incubated with MMP1 enzyme. The half-maximum inhibitory concentration for Col-I 5Fu@G5AuNP was eight times lower than the 5Fu against MCF-7, suggesting the improved delivery and anticancer activity of 5Fu after encapsulation in the developed enzyme-responsive nanocarrier system. The computed tomography (CT) X-ray attenuation of Col-I@G5AuNP showed a good contrasting property. CONCLUSION: The formulation Col-I 5Fu@G5AuNP has improved anticancer activity than free drug and the CT imaging results are promising for its theranostic applications for breast cancer treatment.

Biotinylated Mn3O4 nanocuboids for targeted delivery of gemcitabine hydrochloride to breast cancer and MRI applications.

Multifunctional nanocarriers have been found as potential candidate for the targeted drug delivery and imaging applications. Herein, we have developed a biocompatible and pH-responsive manganese oxide nanocuboid system, surface modified with poly (ethylene glycol) bis(amine) and functionalized with biotin (Biotin-PEG-MNCs), for an efficient and targeted delivery of an anticancer drug (gemcitabine, GEM) to the human breast cancer cells. GEM-loaded Biotin-PEG@MNCs showed high drug loading efficiency, controlled release of GEM and excellent storage stability in the physiological buffers and different temperature conditions. GEM-loaded Biotin-PEG@MNCs showed dose- and time-dependent decrease in the viability of human breast cancer cells. Further, it exhibited significantly higher cell growth inhibition than pure GEM which suggested that Biotin-PEG@MNCs has efficiently delivered the GEM into cancerous cells. The role of biotin in the uptake was proved by the competitive binding-based cellular uptake study. A significant decrease in the amount of manganese was observed in biotin pre-treated cancer cells as compared to biotin untreated cancer cells. In MRI studies, Biotin-PEG-MNCs showed both longitudinal and transverse relaxivity about 0.091 and 7.66 mM-1 s-1 at 3.0 T MRI scanner, respectively. Overall, the developed Biotin-PEG-MNCs presents a significant potential in formulation development for cancer treatment via targeted drug delivery and enhanced MRI contrast imaging properties.

A Rare Presentation of Checkpoint Inhibitor Induced Distal RTA.

Immune checkpoint inhibitors have opened a new era in treating advanced malignancies, resulting in a rapid increase in utilization, given the remarkable clinical outcomes. The incidence of immune-related adverse events increased due to the immunologic effects of these therapeutic agents. However, immune-related renal adverse events remain low, representing only a small incidence of reported cases. Common renal toxicity described includes acute interstitial nephritis, minimal change disease, and immune complex glomerulonephritis. Renal tubular acidosis has occasionally been reported but is highly uncommon. This report presents a case of a 68-year-old woman with a known history of metastatic melanoma undergoing treatment with ipilimumab+nivolumab, who developed distal renal tubular acidosis requiring stress dose steroids and sodium bicarbonate for treatment. We describe the clinical characteristics, potential mechanisms, and management of this case, highlighting the need among clinicians utilizing immune check inhibitors to be aware of this immune-related disease entity.

Pembrolizumab-Induced Hypophysitis With Isolated Adrenocorticotropic Hormone (ACTH) Deficiency: A Rare Immune-Mediated Adverse Event.

Pembrolizumab is an immune checkpoint inhibitor that targets the programmed cell death protein 1 antigen to stimulate an immune response against tumor cells. It has successfully induced remission in patients with severe metastatic disease, including those refractory to other chemotherapeutic regimens. Immune checkpoint inhibitors may result in immune-related adverse events affecting multiple organs, including endocrine organs, leading to thyroiditis and hypophysitis, among others. Isolated adrenocorticotropic hormone deficiency and hypophysitis have been reported in patients treated with nivolumab, another programmed cell death protein 1 inhibitor. However, clinical characteristics of these side effects associated with pembrolizumab have yet to be described in detail. We describe a case of an 85-year-old Caucasian male undergoing treatment of metastatic urothelial carcinoma with pembrolizumab, who abruptly developed hypophysitis requiring emergent intervention.

Clinical Presentation of Hepatocellular Carcinoma in African Americans vs. Caucasians: A Retrospective Analysis.

Hepatocellular carcinoma (HCC) remains an important form of cancer-related morbidity and mortality in the U.S. and worldwide. Previous U.S.-based studies on survival suggest ethnic disparities in HCC patients, but the complex interplay of multiple factors that contribute are still incompletely understood. Here we considered the influences of risk factors contributing towards HCC survival, including ethnic background, over ten years at a premier academic medical center with a majority (57.20%) African American (AA) population. Retrospective HCC data were collected from 2008-2018 at LSUHSC-Shreveport, an urban tertiary medical center. Data included demographics, comorbidities, liver disease characteristics, and tumor parameters. Statistical analysis was performed using Chi Square and one-way ANOVA. Results: 229 HCC patients were identified (male 78.6%). The mean HCC age at diagnosis was 61 years (SD = 7.3). Compared to non-Hispanic Caucasians (42.7%), AA patients (57.2% of total) were older at presentation, had more frequent diabetes/dyslipidemia/NAFLD (45 (34.3%) compared with 19 (19.3%) in non-Hispanic Caucasians, p = 0.02), and had a larger HCC burden at diagnosis. We conclude that compared to white patients, despite having similar BMI and MELD scores and rates of portal vein thrombosis, AA patients with HCC in our cohort were older at presentation, had a significantly increased incidence of modifiable metabolic risk factors including diabetes, higher AFP values, increased incidence of gallstones, and larger sized HCCs, and were more likely to be outside Milan criteria. These findings have important prognostic and diagnostic implications for developing a more targeted HCC surveillance program.

Trainee participation during screening colonoscopy does not affect ADR at subsequent surveillance, but may result in early follow-up.

Background and study aims Training future endoscopists is essential to meet rising demands for screening and surveillance colonoscopies. Studies have shown conflicting results regarding the influence of trainees on adenoma detection rates (ADR). It is unclear whether trainee participation during screening adversely affects ADR at subsequent surveillance and whether it alters surveillance recommendations. Patients and methods A retrospective analysis of average-risk screening colonoscopies and surveillance exams over a subsequent 10-year period was performed. The initial inclusion criteria were met by 5208 screening and 2285 surveillance exams. Patients with poor preparation were excluded. The final analysis included 7106 procedures, including 4922 screening colonoscopies and 2184 surveillance exams. Data were collected from pathology and endoscopy electronic databases. The primary outcome was the ADR with and without trainee participation. Surveillance recommendations were analyzed as a secondary outcome. Results Trainees participated in 1131 (23 %) screening and in 232 (11 %) surveillance exams. ADR did not significantly differ ( P  = 0.19) for screening exams with trainee participation (19.5 %) or those without (21.4 %). ADRs were higher at surveillance exams with (22.4 %) and without (27.5 %) trainee participation. ADR at surveillance was not adversely affected by trainee participation during the previous colonoscopy. Shorter surveillance intervals were given more frequently if trainees participated during the initial screening procedure ( P  = 0.0001). Conclusions ADR did not significantly differ in screening or surveillance colonoscopies with or without trainee participation. ADR at surveillance was not adversely affected by trainee participation during the previous screening exam. However, trainee participation may result in shorter surveillance recommendations.

Anti-N-methyl-d-aspartate Receptor Encephalitis Related Sinus Node Dysfunction and the Lock-Step Phenomenon.

Described in 2007, anti-N-methyl-d-aspartate receptor encephalitis (ANMDARE) is a rare autoimmune limbic encephalitis affecting young adults (predominantly women of reproductive age) and is a paraneoplastic manifestation of ovarian teratoma in about half of the cases. ANMDARE is characterized by psychiatric changes, neurological changes, autonomic instability and cardiac dysrhythmias. In this report, we present a 36-year-old woman who was 16 weeks pregnant and brought to the hospital with confusion and subsequently had a seizure with Electroencephalography (EEG) demonstrated an extreme delta brush pattern consistent with ANMDARE. Patient developed sinus nodal dysfunction and was also found to have ovarian teratoma, a rather typical presentation for ANMDARE, that is considered a paraneoplastic syndrome for ovarian teratoma. In this report, we highlight the cardiac manifestation of ANMDARE, the pathophysiology associated with autonomic instability, and management strategies of this rare, and largely devastating illness.

Inulin-pluronic-stearic acid based double folded nanomicelles for pH-responsive delivery of resveratrol.

Herein, we introduce a novel amphiphilic bioconjugate (INU-F68-SA), synthesized by functionalization of pluronic F68 with a polysaccharide inulin (INU) and a lipid stearic acid (SA). The synthesis of INU-F68-SA was confirmed by FTIR and 1H-NMR analysis. INU-F68-SA can self-assemble into nanomicelles and therefore, its application in delivering of hydrophobic resveratrol (RSV) was investigated. The RSV-loaded INU-F68-SA nanomicelles (RSNM) had about 172 nm size, spherical shape, 0.237 polydispersity index, and -18 mV zeta potential. More importantly, the RSNM showed high drug entrapment efficiency, controlled drug release and protection of drug during storage. The RSNM significantly enhanced the cytotoxicity of RSV against colorectal cancer cells by inducing apoptosis and changing mitochondrial membrane potential. Further, in-vivo pharmacokinetic experiment indicated an improvement in pharmacokinetics of RSV after administering as RSNM. Thus, the use of self-assembled nanomicelles of amphiphilic INU-F68-SA bioconjugate could be a better alternative to overcome the poor in-vitro and in-vivo performance of RSV.

Modulating the Delivery of 5-Fluorouracil to Human Colon Cancer Cells Using Multifunctional Arginine-Coated Manganese Oxide Nanocuboids with MRI Properties.

5-Fluorouracil (5-FU) is one of the most prescribed drugs and the major component of chemotherapy for the treatment of colorectal cancer. In this study, we have designed arginine-functionalized manganese oxide nanocuboids (Arg@MNCs) for the effective delivery of 5-FU to colon cancer cells. Arginine was used as multifunctional agent to provide stability to MNCs, achieve high drug loading, control the release of loaded drug, and improve delivery to cancer cells. The synthesized Arg@MNCs were characterized by DLS, TEM, XRD, FTIR, XPS, TGA, and VSM analysis. The structural and morphological analysis by TEM showed cuboid-shaped MNCs with average particle size ∼15 nm. Biodegradation studies indicated that the Arg@MNCs were degraded at endolyosomal pH in 24 h while remaining stable at physiological pH. Hemolytic toxicity studies revealed the safety and nontoxic nature of the prepared MNCs. 5-FU-loaded Arg@MNCs showed significant control over the release of 5-FU, decrease in the hemolytic toxicity of loaded 5-FU but higher in vitro anticancer activity against HCT 116 and SW480 human colon cancer cells. Importantly, both the bare MNCs and Arg@MNCs showed excellent T1 and T2MR relaxivity under 3.0 T MRI scanner. Thus, the nanostructures developed in this study, i.e., 5-FU-Arg@MNCs could overcome the issues of both MNCs (stability) and 5-FU (low drug loading and nonspecificity) and may be used as a multifunctional theranostic nanocarrier for colon cancer treatment.

Infratentorial Supracerebellar Approach for Resection of Midbrain Cavernous Malformation: 3-Dimensional Operative Video.

Cavernous malformations (cavernomas) of the brain stem with recurrent hemorrhage may be amenable to microsurgical resection if they are present close to the surface. The risks of surgery need to be balanced with the natural history of the lesion and the accumulation of neurological deficits and risk to life with multiple hemorrhages. In this 3D operative video, we illustrate the technique for the resection of a dorsally located midbrain cavernous malformation. Informed consent was obtained for this procedure. The cavernoma is accessed with the use of a supracerebellar infratentorial approach. The infratentorial craniotomy and coagulation of the superior vermian veins is shown. A description is provided of the use of hemosiderin staining and the intercollicular relative "safe zone"1 as landmarks for the neurotomy. The technique of cavernoma dissection from the surrounding gliotic plane is shown and described. In this case, the patient required prolonged rehabilitation but fully recovered without residual deficit 1 yr following surgery.

Novel Cell-Penetrating Peptide Conjugated Proteasome Inhibitors: Anticancer and Antifungal Investigations.

Cell-penetrating peptide conjugated peptide aldehydes Tat-A and Tat-B showed low micromolar anticancer and antifungal activities and synergistic action in combination with cisplatin and amphotericin B against cancer and fungal cells, respectively. Tat-A and Tat-B were significantly more potent than Ixazomib in inhibiting the human 20S proteasomes with IC50 values in the low nanomolar range. Treatment with Tat-A and Tat-B caused membrane disruption and pore formation in HeLa and BE(2)-C cells and inhibition and eradication of C. albicans biofilms. Apoptotic cell death of the treated HeLa and BE(2)-C cells was demonstrated by Annexin V/PI staining. Flow cytometry analyses showed that more than 78% (HeLa) and 92% (BE(2)-C cells showed signs of apoptosis and necrosis upon treatment with Tat-A and Tat-B. This study forms the first report that documents the benefits of cell-penetrating peptide conjugation to enhance the potential of peptide aldehydes as therapeutics.

Delayed Cerebral Metastasis of Breast Cancer: Case Report and Molecular Review

Breast cancer (BC) is a prevalent disease, and its incidence of brain metastasis (BM) varies from5 to 30% according to the literature.We present the case of a delayed isolated cerebral metastasis in a female patient following a period of 16 years after the diagnosis and first treatment. During this time, there was no other recurrence. We also review the literature concerning central nervous systemspread and themolecular subtypes of such late tumors.

Current Controversies Concerning Capsule Endoscopy.

Video capsule endoscopy became a reality in 2001. This device enabled us to directly view the mucosa of the small intestine for the first time. The main indications for the video capsule remain the detection of small intestinal bleeding and iron deficiency anemia, diagnosis and management of Crohn's disease, and detection of tumors. The device is extraordinarily safe and can be used in the very young to the very old. However, there remain several areas of controversy and difficulty. These are covered in this article and include details of indications and contraindications, whether to prepare patients, whether or not to use simethicone and prokinetics. Detection of location of the capsule remains a major engineering challenge. Reading the videos reliably and quickly remains challenging. However, artificial intelligence and machine learning are already on the horizon to provide assistance. New uses for capsule endoscopy promise more accurate diagnosis and hence improved management of acute gastrointestinal bleeding. The colon capsule may eventually help those who refuse conventional colonoscopy, and robotically controlled capsules may be helpful in screening for serious disease in patients with upper abdominal complaints. The advent of the broadening use of video capsule endoscopy is, though it will be controversial, embraced by some and derided by others; such is the nature of technological development. In the long run, if the use of the video capsule, based on sound evidence-based studies, can be shown to improve the care of our patients and reduce the cost of health care, its use will continue to expand.

The endoscopic transpterional port approach: anatomy, technique, and initial clinical experience.

OBJECTIVE: The evolution of microsurgical and endoscopic techniques has allowed the development of less invasive transcranial approaches. The authors describe a purely endoscopic transpterional port craniotomy to access lesions involving the cavernous sinus and the anterolateral skull base. METHODS: Through single- or dual-port incisions and with direct endoscopic visualization, the authors performed an endoscopic transpterional port approach (ETPA) using a 4-mm straight endoscope in 8 sides of 4 formalin-fixed cadaveric heads injected with colored latex. A main working port incision is made just below the superior temporal line and behind the hairline. An optional 0.5- to 1-cm second skin port incision is made on the lateral supraorbital region, allowing multiangle endoscopic visualization and maneuverability. A 1.5- to 2-cm craniotomy centered over the pterion is done through the main port, which allows an extradural exposure of the cavernous sinus region and extra/intradural exposure of the frontal and temporal cranial fossae. The authors present a pilot surgical series of 17 ETPA procedures and analyze the surgical indications and clinical outcomes retrospectively. RESULTS: The initial stage of this work on cadavers provided familiarity with the technique, standardized its steps, and showed its anatomical limits. The clinical ETPA was applied to gain access into the cavernous sinus, as well as for aneurysm clipping and meningioma resection. Overall, perioperative complications occurred in 1 patient (6%), there was no mortality, and at last follow-up all patients had a modified Rankin Scale score of 0 or 1. CONCLUSIONS: The ETPA provides a less invasive, focused, and direct route to the cavernous sinus, and to the frontal and temporal cranial fossae, and it is feasible in clinical practice for selected indications with good results.