Seat Belt Injury and Efferent Loop Laceration Following a Single Anastomosis Duodenal Switch: A Case Report.

Blunt abdominal trauma patients who have had prior bariatric procedures may present a diagnostic and therapeutic challenge. The single anastomosis duodenal-ileal bypass with sleeve (SADI-S) is a modified duodenal switch procedure that is relatively uncommon. This case report describes a patient who previously underwent a SADI-S for the management of obesity and subsequently sustained a seat belt injury in a motor vehicle collision resulting in a laceration of the efferent loop. The patient presented with symptoms of acute abdominal pain and was diagnosed through imaging studies. Prompt surgical intervention was performed with resection and primary anastomosis of the damaged section of the jejunum, and repair of a large mesenteric laceration. We discuss the importance of early recognition and intraoperative decision-making in the case of this patient concerning her SADI-S.

Treatment of acute relapses in neuromyelitis optica: Steroids alone versus steroids plus plasma exchange.

BACKGROUND: Although adding plasma exchange (PLEX) to steroids in severe neuromyelitis optica (NMO) attacks is common practice in steroid-resistant cases, the benefit of this strategy has not been previously quantified. OBJECTIVE: The objective of this paper is to compare the efficacy of high-dose intravenous methylprednisolone (IVMP) versus IVMP+PLEX in treatment of acute NMO relapses. METHODS: We conducted a retrospective review of the last 83 NMO admissions to the Johns Hopkins Hospital treated with IVMP alone versus IVMP+PLEX (for steroid-resistant cases). Extended Disability Status Scale (EDSS) score was calculated at baseline, at presentation, at discharge, and on follow-up. RESULTS: Eighteen NMO relapses (16 patients, 87% female, mean age at relapse: 33.9±23.8, median baseline EDSS 2.5) were treated with IVMP alone and 65 relapses (43 patients, 95% female, mean age at relapse: 43.8±15.7, median baseline EDSS 5.75) were treated with IVMP + PLEX. Sixty-five percent of IVMP + PLEX patients achieved an EDSS equal or below their baseline at follow-up while only 35% of the IVMP-only patients achieved their baseline EDSS on follow-up (odds ratio=3.36, 95% CI 1.0657 to 10.6004, p = 0.0386). PLEX was more effective in improving EDSS in patients on preventive immunosuppressive medications at time of relapse. CONCLUSIONS: PLEX+IVMP are more likely to improve EDSS after NMO relapses compared to IVMP alone, especially in patients taking preventive medications.

Lateral transzygomatic middle fossa approach and its extensions: surgical technique and 3D anatomy.

BACKGROUND: Various approaches to lesions involving the middle fossa and cavernous sinus (CS), with and without posterior fossa extension have been described. In the present study, we describe the surgical technique for the extradural lateral tranzygomatic middle fossa approach and its extensions, highlight relevant 3D anatomy. METHODS: Simulations of the lateral transzygomatic middle fossa approach and its extensions were performed in four silicon-injected formalin fixed cadaveric heads. The step-by-step description and relevant anatomy was documented with 3D photographs. RESULT: The lateral transzygomatic middle fossa approach is particularly useful for lesions involving the middle fossa with and without CS invasion, extending to the posterior fossa and involving the clinoidal region. This approach incorporates direct lateral positioning of patient, frontotemporal craniotomy with zygomatic arch osteotomy, extradural elevation of the temporal lobe, and delamination of the outer layer of the lateral CS wall. Extradural drilling of the sphenoid wing and anterior clinoid process allows entry into the CS through the superior wall and exposure of the clinoidal segment of the ICA. Posteriorly, drilling the petrous apex allows exposure of the ventral brainstem from trigeminal to facial nerve and can be extended to the interpeduncular fossa by division of the superior petrosal sinus. CONCLUSION: The present study illustrates 3D anatomical relationships of the lateral transzygomatic middle fossa approach with its extensions. This approach allows wide access to different topographic areas (clinoidal region and clinoidal ICA, the entire CS, and the posterior fossa from the interpeduncular fossa to the facial nerve) via a lateral trajectory. Precise knowledge of technique and anatomy is necessary to properly execute this approach.