Robotic excision of a retrocaval ancient schwannoma: a case report.

We report a case of a robotic-assisted excision of a retrocaval ancient schwannoma. A 40-year-old female presented with generalized weakness and abdominal pain that led to the diagnosis of a retroperitoneal mass adjacent to the pancreas and inferior vena cava. Because of the clinical, imaging, and needle biopsy findings, the patient underwent an elective robotic-assisted retroperitoneal exploration. We provide an overview of the pathology and highlight the significance of utilizing a minimally invasive approach for excision of retroperitoneal masses.

Perforated pre-pyloric ulcer in the gastric remnant over a decade after Roux-en-Y gastric bypass: A case report.

INTRODUCTION AND IMPORTANCE: Roux-en-Y gastric bypass (RYGB) is one of the two most common weight loss surgeries. Surgical emergencies after gastric bypass can be complicated by devastating events that are often difficult to diagnose and manage. Perforated ulcers are a very rare complication after a RYGB. CASE PRESENTATION: In this report, the diagnosis and surgical management of a 59-year-old immunosuppressed male patient who presented with late perforation of a pre-pyloric ulcer in the gastric remnant after RYGB is presented. The perforation was repaired transversely in a running horizontal mattress fashion and patched with a piece of well-vascularized omentum. CLINICAL DISCUSSION: This case illustrates the potential for gastric remnant ulceration, even a decade after RYGB. A high degree of suspicion for the diagnosis of perforated remnant stomach is required, especially in the absence of pneumoperitoneum and free fluid. Patient-specific factors, such as immunosuppression in this case, may blunt normal physiologic response. CONCLUSION: Considering the location of the ulcer in the pre-pyloric area, we caution that the typical paradigm of marginal ulceration of the gastro-jejunal anastomosis does not always apply when evaluating gastric complications after RYGB.

Surgical Management of Lumbosacral Plexus Tumors.

BACKGROUND: Lumbosacral plexus tumors are uncommon, and because of their deep location and proximity to critical nerves subserving lower extremity function, understanding surgical approaches and short-term outcomes is important. METHODS: In a retrospective case series of lumbosacral plexus tumor surgeries performed from May 2000 to July 2021 by a single neurosurgeon, demographic information, clinical presentation, imaging studies, and operative outcomes were analyzed. RESULTS: A total of 42 patients with mean age of 48.3 years (range, 16-84 years) underwent surgery for a lumbosacral plexus tumor. Patients presented with leg pain (n = 25; 59.5%), followed by back/flank pain (n = 5; 11.9%), abdominal/pelvic pain (n = 5; 11.9%), leg weakness (n = 5; 11.9%), and leg numbness (n = 3; 7.1%). The most common tumor pathology was schwannoma (n = 20; 50.0%) followed by neurofibroma (n = 9; 22.5%). A retroperitoneal approach was used in all cases. Gross total resection was achieved in 23 (54.8%) patients, and only 1 (2.4%) patient exhibited symptomatic tumor recurrence after subtotal resection of a malignant tumor. Mean follow-up was 33.1 months (range, 1-96 months). Postoperatively, patient neurological status remained unchanged or improved (n = 37; 88.1%). Complications were infrequent, with 4 (9.5%) patients experiencing new sensory symptoms and 1 patient (2.4%) experiencing new anticipated motor weakness after en bloc resection of a malignant tumor. CONCLUSIONS: Indications for surgery include pain and/or neurological symptoms attributable to the lesion or large size if asymptomatic. Careful study of preoperative imaging is necessary to determine the best approach. Intraoperative nerve stimulation is essential to preserve function and guide extent of resection in benign tumors.

Second Gamma Knife Treatment for Trigeminal Neuralgia: Anterior Target Spacing and 25 Gy as the Second Dose.

Objective Gamma Knife® radiosurgery (GKRS) has been demonstrated to be a well-known approach for treating patients with medical refractory trigeminal neuralgia (TN). Herein, the authors review the outcomes of pain among a large cohort of patients who had undergone a second GKRS delivered at a significantly reduced dose. Methods The authors conducted a prospective analysis of patients who have undergone two GKRS procedures between the years 2012 to 2021 at one institution. Baseline characteristics, radiosurgical dosimetry and technique, pain outcomes, and adverse effects were reviewed. Pain outcomes were measured with the Barrow Neurological Institute (BNI) pain intensity scale, which included the best BNI attained after the last treatment and recurrence. Results A total of 202 patients were identified, including 55 males and 147 females. Pain recurrence was reported in all patients prior to the second GKRS treatment (median = 4 months). Pain recurrence in the preceding Japan Neuroscience Society (JNS) 2021 study was also reported in all patients after each GKRS with a median value of 20 months between the second and third procedures. Complete to partial pain relief (BNI ≤ III) was achieved in 80% of patients after the second treatment. Over a median of 12 months of follow-up, 60% of patients maintained complete to partial pain relief compared to 77% of patients over the course of three treatments. In the present study, one patient developed facial spasms while 10 patients experienced persistent facial tingling. Subjective mild numbness was also found to be present in 16% of patients, with only 2% being bothersome, as compared to the JNS study, where subjective mild numbness was found to be present in 14%, with only 14.3% being bothersome. Among the 202 patients, 74 (37%) patients had undergone subsequent additional procedures such as a third GKRS, microvascular decompression (MVD), or other percutaneous procedures. Conclusion The authors describe the largest study to date of patients undergoing a second GKRS treatment for type 1 medical refractory trigeminal neuralgia. A reduced dose of radiation for a second treatment may produce outcomes similar to those of three consecutive treatments in regard to limiting recurrence and adverse effects.