Sphenoidal meningoencephalocele associated with CSF fistula and arteriovenous malformation Spetzler-Martin V: A case report / Meningoencefalocele esfenoidal asociado a fístula de líquido cefalorraquídeo y malformación arteriovenosa Spetzler-Martin V: reporte de caso

Cerebral Arteriovenous malformations (AVMs) are presumed congenital anomalies of the blood vessels, which can increase intracranial pressure by uncertain mechanisms. We report the rare case of a 55-year-old male patient who complained about CSF rhinorrhea. Persisting CSF leakage prompted CT, which evidenced a bone defect in the right middle cranial fossa with protruding brain tissue. The diagnosis of a sphenoidal meningoencephalocele was made. Neuroimaging evidenced an AVM Spetzler Martin V. The lesion was targeted via an endonasal approach with resection of the herniated brain tissue and closure of the bony and dural defects. The postoperative course was uneventful without recurrence of the CSF fistula. Documentation of these cases is essential to come up with standardized therapeutical protocols and follow-up. Nevertheless, conservative management of the AVM and surgical repair of the bone defects is an appropriate approach in the first instance, depending on the morphology and characterization of the AVM (AU)

Las malformaciones arteriovenosas (MAV) son consideradas anomalías congénitas de los vasos sanguíneos; estas pueden aumentar la presión intracraneal a través de mecanismos inciertos. Reportamos el caso de un hombre de 55 años con presencia de rinolicuorrea de larga data. Se realizó la toma de una TC de cráneo, evidenciando un defecto óseo en la fosa craneal media derecha con protrusión de tejido cerebral, diagnosticando un meningoencefalocele esfenoidal. Las imágenes complementarias evidenciaron una MAV Spetzler-Martin V. La lesión fue tratada con un abordaje endonasal resecando el tejido cerebral herniado con cierre de los defectos dural y óseo. En el postoperatorio no hubo recurrencia de rinolicuorrea. La documentación de estos casos es esencial para generar protocolos estandarizados de tratamiento y seguimiento. En nuestra experiencia el manejo conservador de la MAV y el reparo quirúrgico de los defectos es un abordaje adecuado, teniendo en cuenta la morfología y caracterización de la MAV (AU)

Cuantificación de la fibrosis auricular derecha mediante resonancia magnética cardiaca: verificación del método para la estandarización de umbrales' / Quantification of right atrial fibrosis by cardiac magnetic resonance: verification of the method to standardize thresholds

Introducción y objetivos La resonancia magnética cardiaca con realce tardío de gadolinio (RMC-RTG) permite la detección no invasiva de la fibrosis auricular izquierda en pacientes con fibrilación auricular (FA). Sin embargo, se desconoce si se puede utilizar la misma metodología en la aurícula derecha (AD). Nuestro objetivo fue definir un umbral estandarizado para caracterizar la fibrosis auricular derecha mediante RMC-RTG. Métodos Se realizaron RMC-RTG de 3 T en 53 personas; se segmentó la AD y se calculó la razón de intensidad de imagen (RII) para la pared de la AD utilizando 1.557.767 píxeles de RII (40.994±10.693 por paciente). El límite superior de la normalidad de la RII (RII promedio+2 desviaciones estándar) se estimó en voluntarios sanos (n = 9); para establecer el umbral de cicatriz densa, se utilizó a los pacientes que se habían sometido previamente a una ablación del flutter auricular típico (n = 9). Se incluyó a pacientes con FA paroxística y persistente (n=10 cada grupo) para la validación. Los valores de RII se correlacionaron con un mapa de voltaje bipolar de alta densidad en 15 pacientes sometidos a ablación de FA. Resultados El límite superior de la normalidad (umbral de fibrosis total) en voluntarios sanos se fijó en RII = 1,21. En el grupo postablación, el 60% del píxel de la RII máximo (umbral de fibrosis densa) se calculó como RII = 1,29. El voltaje bipolar endocárdico mostró una correlación con la RII débil pero significativa. La precisión general entre el mapa electroanatómico y la RMC-RTG para caracterizar la fibrosis fue del 56%. Conclusiones Se determinó una RII > 1,21 como umbral para la detección de fibrosis de la aurícula derecha, mientras que una RII > 1,29 diferencia la fibrosis intersticial de la cicatriz densa. A pesar de las diferencias entre las aurículas izquierda y derecha, se pudo evaluar la fibrosis con RMC-RTG con umbrales similares en ambas cámaras (AU)

Introduction and objectives Late gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) allows noninvasive detection of left atrial fibrosis in patients with atrial fibrillation (AF). However, whether the same methodology can be used in the right atrium (RA) remains unknown. Our aim was to define a standardized threshold to characterize RA fibrosis in LGE-CMR. Methods A 3 Tesla LGE-CMR was performed in 53 individuals; the RA was segmented, and the image intensity ratio (IIR) calculated for the RA wall using 1 557 767 IIR pixels (40 994±10 693 per patient). The upper limit of normality of the IIR (mean IIR+2 standard deviations) was estimated in healthy volunteers (n=9), and patients who had undergone previous typical atrial flutter ablation (n=9) were used to establish the dense scar threshold. Paroxysmal and persistent AF patients (n=10 each) were used for validation. IIR values were correlated with a high-density bipolar voltage map in 15 patients undergoing AF ablation. Results The upper normality limit (total fibrosis threshold) in healthy volunteers was set at an IIR = 1.21. In the postablation group, 60% of the maximum IIR pixel (dense fibrosis threshold) was calculated as IIR = 1.29. Endocardial bipolar voltage showed a weak but significant correlation with IIR. The overall accuracy between the electroanatomical map and LGE-CMR to characterize fibrosis was 56%. Conclusions An IIR > 1.21 was determined to be the threshold for the detection of right atrial fibrosis, while an IIR > 1.29 differentiates interstitial fibrosis from dense scar. Despite differences between the left and right atria, fibrosis could be assessed with LGE-CMR using similar thresholds in both chambers (AU)

Comparison of early period sexual function parameters between surgical repair and conservative treatment after penile fracture / Comparación de los parámetros de función sexual en el período temprano entre la reparación quirúrgica y el tratamiento conservador después de una fractura de pene

Introduction and objectives: Comparison of early period sexual function parameters in patients who had surgical repair and conservative follow-up after penile fracture and the evaluation of surgical intervention time on these parameters were planned in this study. Materials and methods: Total of 26 patients who were treated for penile fracture were evaluated. 19 patients had surgical repair and 7 patients had conservative treatment.Sexual function and erectile dysfunction (ED) degree of the patients before penile fracture and in the 12th week after fracture were evaluated with 5-question International Index of Erectile Function (IIEF-5) questionnaire, Erection Hardness Score (EHS), Sexual Encounter Profile(SEP) 2 and SEP 3. Parameters showing sexual function before and after the fracture were compared. Results: In both groups, a significant change was detected in IIEF-5 score, EHS, SEP-2 and SEP-3 parameters of the patients measured after penile fracture compared to the values before the fracture (all parameters, p<0.05). No difference was detected in the parameters measured before and after the fracture among surgical repair and conservative treatment groups (all parameters p>0.05). Mean time passing until the surgery after fracture was measured as 9.6±6.85h in 19 patients who had surgery. Conclusion: A difference wasn’t detected in sexual parameters in conservative treatment and surgical repair groups in this study. As a significant decrease was observed in sexual function parameters even in conservative treatment cases without sudden detumescence and tunica albuginea rupturing, we think that quick surgical exploration would be useful in cases considered to have penile fracture. (AU)

Introducción y objetivos: En este estudio se planificó la comparación de los parámetros de función sexual en el período temprano en pacientes sometidos a reparación quirúrgica y seguimiento conservador después de una fractura de pene y la evaluación del tiempo de intervención quirúrgica sobre estos parámetros. Materiales y métodos: Se evaluaron un total de 26 pacientes que fueron tratados por fractura de pene: 19 fueron sometidos a reparación quirúrgica y 7 tuvieron un seguimiento conservador. La función sexual y el grado de disfunción eréctil de los pacientes antes de la fractura de pene y en la semana 12 después de la fractura se evaluaron con el cuestionario International Index of Erectile Function de 5 preguntas (IIEF-5), el Erection Hardness Score (EHS), y el Sexual Encounter Profile (SEP) 2 y SEP 3. Se compararon los parámetros que muestran la función sexual antes y después de la fractura. Resultados: En ambos grupos se detectó un cambio significativo en la puntuación IIEF-5 y los parámetros EHS, SEP 2 y SEP 3 de los pacientes medidos después de la fractura de pene en comparación con los valores antes de la fractura (todos los parámetros, p<0,05). No se detectaron diferencias en los parámetros medidos antes y después de la fractura entre los grupos de reparación quirúrgica y tratamiento conservador (todos los parámetros p>0,05). El tiempo medio transcurrido hasta la cirugía después de la fractura se midió como 9,6±6,85h en los 19 pacientes intervenidos. Conclusión: No se detectaron diferencias en los parámetros sexuales entre los grupos de observancia conservadora y reparación quirúrgica en este estudio. Como se observó una disminución significativa de los parámetros de función sexual incluso en casos de seguimiento conservador sin detumescencia súbita y desgarro de la túnica albugínea, pensamos que la exploración quirúrgica rápida sería útil en los casos en los que se considere que tienen fractura de pene. (AU)

Neumoencéfalo, coma y convulsiones después de una cirugía de descompresión lumbar / Pneumocephalus, coma and seizures following lumbar decompression surgery

Describimos un caso de neumoencéfalo en una paciente con estenosis de canal medular por espondilolistesis degenerativa tras cirugía de descompresión lumbar. El caso comienza en el momento del despertar de la anestesia, en el que la paciente presenta bajo nivel de consciencia, sin respuesta de apertura ocular, ninguna respuesta verbal y la respuesta motora sOlo retira en respuesta al dolor (Glasgow 7), que precisa ingreso en la unidad de cuidados intensivos para ventilación mecánica. Posteriormente la paciente experimentó una crisis convulsiva tónico-clónica generalizada, por lo que se realizó una tomografía computarizada (TC) donde se observa un neumoencéfalo voluminoso con un efecto ocupante de espacio en los lóbulos frontal y parietal, los ventrículos laterales y la cisterna.Se inició terapia antiepiléptica (diazepam y levetiracetam) y vigilancia neurológica. A las 12h postoperatorias, la TC repetida demostró que el neumoencéfalo había mejorado persistiendo una cantidad mínima que Solo se limitaba al lóbulo frontal. La consciencia persistía severamente disminuida. El electroencefalograma mostró actividad epileptiforme continua y la adicción de fenitoína continua intravenosa al tratamiento antiepiléptico previo consigue mejorar gradualmente el nivel de consciencia y las respuestas motoras y verbales. A las pocas horas, la paciente fue extubada y no presentó déficits neurológicos posteriores. El neumoencéfalo debe considerarse en el diagnóstico diferencial cuando se evalúa a un paciente con un estado mental alterado después de una cirugía lumbar.(AU)

We describe a patient with pneumocephalus following lumbar decompression surgery who presented altered mental status at time to awake of anesthesia and the patient was admitted in intesive care unit in mechanical ventilation. The patient has not eye-opening response, no verbal response and motor response only withdraw in response to pain (7 points on Glasgow coma scale). Then, the patient experienced a generalized tonic-clonic seizure. Immediate cranial computed tomography (CT) images were performed. Cerebral pneumocephalus was present in CT, imaging revealed a voluminous pneumocephalus responsible for a significantspace-occupying effect on the frontal and parietal lobes, lateral ventricles and quadrigeminal plate cistern.Anti-epileptic therapy (diazepam and levetiracetam) and neurological monitoring were initiated. At 12 postoperative hours repeat CT scanning showed pneumocephalus were completely improved to minimal quantity and only limited to frontal lobe. The consciousness is impaired, and a generalized tonic-clonic seizure was present. Electroencephalogram showed continuous epileptiform activity and phenytoin IV was administered in continuous infusión. Four hours later the level of consciousness gradually improved, and the patient was right in eye opening, verbal and motor responses. A few hours later the patient was extubated, and no neurological deficits were present. Pneumocephalus should be considered in the differential diagnosis when evaluating a patient with altered mental status following lumbar surgery.(AU)

Oftalmomiasis orbitaria por Dermatobia hominis en un paciente inmunosuprimido en un área andina ecuatoriana / Orbital ophthalmomiasis due to Dermatobia hominis in an immunosuppressed patient from the ecuadorian andean area

Varón ecuatoriano de 83 años, indigente, con antecedente de desnutrición y alcoholismo crónico, acude por un cuadro clínico caracterizado por crecimiento progresivo de larvas a nivel ocular izquierdo (OI), asociado a áreas de putrefacción de tejidos oculares. Al ingreso, su visión en ojo derecho (OD) fue de movimiento de manos y el OI indicaba no percepción de luz, el segmento anterior de OD evidenció una catarata brunescente, sin otra alteración, mientras que el OI presentó edema, eritema bipalpebral y abundante cantidad de larvas móviles distribuidas en toda la órbita, asociado a áreas de necrosis, putrefacción y distorsión de la anatomía de los tejidos oculares. La tomografía de órbita mostró un compromiso importante de la órbita, indicándose manejo quirúrgico mediante exenteración orbitaria izquierda con identificación taxonómica de las larvas como Dermatobia hominis, asociado a ello, se implementó tratamiento antibiótico y realización de un colgajo fasciocutáneo frontal por el Departamento de Cirugía Plástica (AU)

An 83-year-old Ecuadorian male, indigent with a history of malnutrition and chronic alcoholism, presented with a clinical feature characterized by progressive growth of larvae at the left eye level (LE), associated with areas of ocular tissue putrefaction. Upon admission, his vision in the right eye (RE) was of hand movement and no light perception in LE, the anterior segment of the RE showed a brunescent cataract, with no other alteration, while the LE presented edema, bipalpebral erythema and an abundant number of mobile larvae distributed throughout the orbit, associated with areas of necrosis, putrefaction and distortion of the anatomy of the ocular tissues. Orbital tomography showed a significant compromise of the orbit, indicating surgical management by left orbital exenteration with taxonomic identification of the larvae as Dermatobia Hominis associated with it, antibiotic treatment was implemented and a frontal fasciocutaneous flap was performed by the plastic surgery department (AU)

Glomus Tumor Within the Tensor Fascia Lata: A Case Report.

BACKGROUND Glomus tumors are rare, benign, soft-tissue lesions, usually occurring in the hand, but they can occur in other regions of the body, such as the thigh. Most of the time, extradigital glomus tumors are difficult to diagnose, and symptoms can persist for a long time. The usual clinical presentations consist of pain, tenderness at the site of the tumor, and hypersensitivity to cold. CASE REPORT We report a case of a GT of the proximal thigh in a 39-year-old man with left thigh pain without palpable mass for several years, without clear diagnosis. He had pain and hyperesthesia exacerbated by running. The patient was diagnosed initially by ultrasound imaging, which revealed a round, solid, hypoechoic, homogeneous mass in the left upper thigh. Magnetic resonance imaging (MRI) with contrast showed a well-defined intramuscular lesion in the tensor fascia lata. A percutaneous biopsy was done through ultrasound guidance, followed by excisional biopsy and immediate pain relief. CONCLUSIONS Glomus tumors of the thigh are a rare neoplasm, especially in the proximal thigh; they are difficult to diagnose and are associated with morbidity. Diagnosis can be made through a systematic approach and simple investigation, such as via ultrasonography. A percutaneous biopsy can help in drawing up a management plan, and malignancy must be considered if the lesion is suspicious. Symptoms can persist in case of incomplete resection or unrecognized synchronous satellite lesions; thus, symptomatic neuroma should be considered.

Co-occurrence of pheochromocytoma and paraganglioma of the organ of Zuckerkandl resected simultaneously by laparoscopy: a rare case report and literature review.

Pheochromocytomas (PHEOs) and paragangliomas are generally grouped as rare chromaffin cell tumors. The co-occurrence of PHEOs and paragangliomas of the organ of Zuckerkandl (POZ) is extremely rare. The most common symptom of pheochromocytoma-paraganglioma (PPGL) is hypertension, and open surgery is still recommended for the treatment of large PPGLs. Herein, we report a case of a successful simultaneous laparoscopic resection of a large PHEO accompanied by POZ in a 40-year-old man with normal blood pressure. DNA analysis revealed a mutation in the succinate dehydrogenase subunit B in both the PHEO and the POZ. To the best of our knowledge, this is the first report of tumors occurring simultaneously in these two locations. We believe that the co-occurrence of PHEO and POZ is extremely rare, and the possibility of PPGL cannot be ruled out in patients with normal blood pressure. The decision to perform laparoscopic surgery remains questionable for patients with a large PHEO and POZ. In addition, a genetic examination should be performed to identify the existence of PPGL-related inherited syndromes.

Potential utility of a multi-component coagulation factor panel to calculate MELD scores and assess the risk of portal vein thrombosis in chronic liver disease.

BACKGROUND: Current quantitative approaches to assess chronic liver disease (CLD) severity have limitations. Further, portal vein thrombosis (PVT) pre-liver transplant (LT) is a major contributor to morbidity in CLD; the means of detecting and/or predicting PVT are limited. We sought to explore whether plasma coagulation factor activity levels can serve as a substitute for prothrombin time/international normalized ratio (PT/INR) in the Model for End-stage Liver Disease (MELD), and/or help assess the risk of PVT. METHODS: Plasma activity levels of Factor V (FV), Factor VIII (FVIII), Protein C (PC), and Protein S (PS) and the concentrations of D-dimer, sP-selectin, and asTF were assessed in two cohorts of CLD patients (ambulatory, n = 42; LT, n = 43). RESULTS: FV and PC activity levels strongly correlated with MELD scores, which enabled the development of a novel scoring system based on multiple linear regressions of the correlations of FV and PC activity with MELD-Na that substitutes PT/INR. Six-month and 1-year follow-up revealed that our novel approach was non-inferior to MELD-Na at predicting mortality. A significant inverse correlation between FVIII activity levels and PVT was found in the LT cohort (p = 0.010); FV and PS activity levels were in-trend (p = 0.069, p = 0.064). We developed a logistic regression-based compensation score to identify patients at risk of PVT. CONCLUSIONS: We demonstrate that FV and PC activity levels may be used to replace PT/INR in MELD scoring. We also show the potential of using the combination of FV, FVIII, and PS activity levels to assess the risk of PVT in CLD.

Laparoscopic Ureterolithotomy and Single-Use Digital Flexible Ureteroscope For Unilateral Large Ureteral Stone and Small Renal Stone.

BACKGROUND The removal of concurrent ureteral and renal stones within a single procedure has always been a challenge for urological surgeons. The incorporation of single-use digital flexible ureteroscopes into laparoscopic ureterolithotomy procedures has demonstrated effective removal of concurrent stones with a good clearance rate and decreased risk of bleeding and trauma. We report the successful removal of a unilateral upper ureteral stone and a smaller renal stone with this procedure. CASE REPORT A 60-year-old man visited the outpatient clinic with an ultrasonography report that revealed a large proximal ureteral stone with moderate hydronephrosis, accompanied by bilateral renal stones and prostatic hyperplasia. He had been experiencing urinary urgency for a year and was determined to undergo lithotomy. Due to his longstanding history of coronary artery disease and myocardial ischemia, the urologists decided that concurrent stone removal within an operation would be the best treatment. A preoperative computed tomography urogram measured the left ureteral and renal stones to be 2.0×0.8 cm and 0.6 cm, respectively. Both stones were successfully removed by laparoscopic ureterolithotomy using a single-use digital flexible ureteroscope. The patient had an uneventful recovery and remained well 1 month post-operation. CONCLUSIONS The application of single-use digital flexible ureteroscopes for laparoscopic ureterolithotomy has demonstrated safety, efficiency, and cost-effectiveness. The authors believe that it is a safe alternative for the removal of concurrent ureteral and renal stones, especially in patients with multiple comorbidities.

Sexual health and sexual well-being of women with Mayer-Rokitansky-Kuester-Hauser syndrome after vaginal reconstruction: a qualitative analysis.

BACKGROUND: Contradictory findings on sexual health in women with Mayer-Rokitansky-Kuester-Hauser syndrome (MRKHS) after vaginal reconstruction point toward the need for more profound assessment of this subject, particularly as it is still unclear what constitutes sexual well-being, especially genital self-image or sexual self-esteem, in women with MRKHS and neovagina. AIM: The aim of this qualitative study was to assess individual sexual health and sexual well-being in the context of MRKHS after vaginal reconstruction, with an emphasis on genital self-image, sexual self-esteem, sexual satisfaction, and coping with MRKHS. METHODS: Qualitative semistructured interviews were conducted with women with MRKHS after vaginal reconstruction (n = 10) with the Wharton-Sheares-George surgical method and a matched control group without MRKHS (n = 20). Women were surveyed about their previous and current sexual activities, perception of and attitudes toward their genitals, disclosure to others, coping with the diagnosis, and perception of surgery. Data were analyzed through qualitative content analysis and compared with the control group. OUTCOMES: The primary outcomes of the study were major categories, such as sexual satisfaction, sexual self-esteem, genital self-image, and dealing with MRKHS, as well as subcategories related to the content analysis. RESULTS: Although half the women in the present study indicated that they were coping well with their condition and were satisfied with sexual intercourse, most felt insecure about their neovagina, were cognitively distracted during intercourse, and showed low levels of sexual self-esteem. CLINICAL IMPLICATIONS: A better understanding of expectations and uncertainties regarding the neovagina might help professionals to support women with MRKHS after vaginal reconstruction to increase sexual well-being. STRENGTHS AND LIMITATIONS: This is the first qualitative study focusing on individual aspects of sexual well-being, especially sexual self-esteem and genital self-image, in women with MRKHS and neovagina. The qualitative study indicates good interrater reliability and data saturation. The limitations of this study include the inherent lack of objectivity resulting from the method but also the fact that all the patients had a particular surgical technique, consequently resulting in limited generalizability of these findings. CONCLUSIONS: Our data indicate that integrating the neovagina into the genital self-image is a prolonged process that is essential for sexual well-being and should thus be the focus of sexual counseling.

Off-Pump Resection of Giant Intramural Left Ventricular Hydatid Cyst by Pleuropericardial Approach: a Case Report.

Primary cardiac hydatid cyst is a rare and fatal pathology, especially when involving the left ventricular free wall. A 44-year-old male was diagnosed with large intramural left ventricular hydatid cyst with wall thickness of 6 mm at the thinnest point. Cyst was accessed through pleuropericardial approach (left pleura opened, followed by entry into cyst directly through adjacent pericardium without removing the pericardial adhesions) which resulted in easy entry into the cyst, mitigating the risk of mechanical injury. This case report highlights that with detailed evaluation, cardiac hydatidosis can be addressed with off-pump technique, reducing the anaphylaxis risks and cardiopulmonary bypass-related effects.

The Effect of Perioperative Fluid Management and Operative Modifications on Mortality and Morbidity in Patients Undergoing Pulmonary Endarterectomy.

INTRODUCTION: Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe disease treated with pulmonary endarterectomy. Our study aims to reveal the differences in liquid modalities and operation modifications, which can affect the patients' mortality and morbidity. METHODS: One hundred twenty-five patients who were diagnosed with CTEPH and underwent pulmonary thromboendarterectomy (PTE) at our center between February 2011 and September 2013 were included in this retrospective study with prospective observation. They were in New York Heart Association functional class II, III, or IV, and mean pulmonary artery pressure was > 40 mmHg. There were two groups, the crystalloid (Group 1) and colloid (Group 2) liquid groups, depending on the treatment fluids. P-value < 0.05 was considered statistically significant. RESULTS: Although the two different fluid types did not show a significant difference in mortality between groups, fluid balance sheets significantly affected the intragroup mortality rate. Negative fluid balance significantly decreased mortality in Group 1 (P<0.01). There was no difference in mortality in positive or negative fluid balance in Group 2 (P>0.05). Mean duration of stay in the intensive care unit (ICU) for Group 1 was 6.2 days and for Group 2 was 5.4 days (P>0.05). Readmission rate to the ICU for respiratory or non-respiratory reasons was 8.3% (n=4) in Group 1 and 11.7% (n=9) in Group 2 (P>0.05). CONCLUSION: Changes in fluid management have an etiological significance on possible complications in patient follow-up. We believe that as new approaches are reported, the number of comorbid events will decrease.

Peripheral nerve injuries in children-prevalence, mechanisms and concomitant injuries: a major trauma center's experience.

BACKGROUND: Peripheral nerve injuries are severe conditions with potential lifelong impairment, which is especially meaningful for the pediatric population. Knowledge on prevalence, injury mechanisms and concomitant injuries is, therefore, of utmost importance to increase clinician awareness and enable early diagnosis and treatment. As current literature on pediatric nerve lesions and concomitant injuries is scarce, we aimed to analyze all details of our patient population. METHODS: A total of 110 667 patients treated at our level 1 trauma center from 2012 to 2021 were evaluated for pediatric peripheral nerve injuries, causes, concomitant injuries and assessed for lesion classification (in continuity, partial lesion, dissection) and further relevant intraoperative findings. RESULTS: We found 5026 patients of all ages with peripheral nerve lesions, whereof 288 were pediatric, resulting in a prevalence of 5.7% of pediatric patients with nerve injuries. Mean age was 12.4 ± 4.6 years. Most common lesions were digital nerves (48.2%), followed by median (14.9%), ulnar (14.6%), radial (8.8%), peroneal nerve (5.2%) and brachial plexus injuries (2.1%). Of all pediatric nerve injuries, 3.8% were iatrogenic, only 30.2% had preserved continuity and 47.3% a concomitant vessel injury. Fractures were accompanied in 22.6%. DISCUSSION: We observed that a large proportion of injures had complete transections, often accompanied by concomitant vessel injuries especially in distally located injuries, highlighting the importance of early surgical exploration. Radial, ulnar and lower extremity nerve injuries were often associated with fractures. Early surgical nerve repair is key to improve motor and sensory outcomes. Knowledge on mechanisms and concomitant injuries facilitates timely diagnosis and treatment, thereby potentially preventing lifelong impairment.

Determining the learning curve for percutaneous endoscopic lumbar interbody fusion for lumbar degenerative diseases.

PURPOSE: Percutaneous endoscopic lumbar interbody fusion (PELIF) is one of the least invasive procedures for lumbar degenerative disorders (LDD). There is limited knowledge of the learning curve for PELIF. METHODS: A total of 93 consecutive patients who underwent PELIF performed by a single spine surgeon for LDD failed with conservative treatment were retrospectively reviewed. The case series was split into three groups based on timing: A (earliest third of patients); B (middle third of patients); and C (latest third of patients). The following were also recorded: operating time, X-ray exposure time, complications, radiologic fusion rates, pre- and postoperative patient-reported outcome measures (PROMs) scores (visual analogue scale (VAS) for back pain, VAS for leg pain, Japanese Orthopaedic Association, Oswestry Disability Index and MacNab criteria), length of hospital stay, and need for revision surgeries. A learning curve was then developed by a logarithmic curve-fit regression analysis. RESULTS: The operative time gradually decreased over time, and an asymptote was reached after about 25 cases. Compared with group B or C, group A had significantly longer operative time, significantly longer length of hospital stay, needed significantly more x-ray exposure time. Though not significantly different, there are fewer complications and revision surgeries over time. There is no significant difference over time in PROMs scores except for the VAS back scores. CONCLUSIONS: PELIF is an alternative for minimal invasive surgery for LDD, PELIF presents a learning curve to the practicing spine surgeon with regard to operative time, x-ray exposure time, length of hospital stay, clinical PROMs and radiographic outcomes and complications. The presented PELIF learning curve provided valuable insight to surgeons interested in performing this surgery.

Full-Endoscopic Interlaminar Approach for Decompression of Lateral Recess Stenosis.

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming more common. Full-endoscopic spinal surgeries have the advantages of being less invasive and offering a shorter recovery time. Here, we describe the technique of the full-endoscopic interlaminar approach for the decompression of lateral recess stenosis. The full-endoscopic interlaminar approach for the lateral recess stenosis procedure took approximately 51 min (range of 39-66 min). Blood loss could not be measured due to continuous irrigation. However, no drainage was required. There were no dura mater injuries reported in our institution. Furthermore, there were no injuries to the nerves, no cauda equine syndrome, and no hematoma formation. The patients were mobilized on the same day as surgery and discharged the next day. Therefore, the full-endoscopic technique for lateral recess stenosis decompression is a feasible procedure that lowers the operational time, complications, traumatization, and rehabilitation duration.

Whole Central and Peripheral Nervous System Mice Dissection.

Animal models represent the workhorse of the neuroscience field. Despite this, today, there is still no step-by-step protocol to dissect a complete rodent nervous system, nor is there a complete schematic representing it that is freely available. Only methods to harvest the brain, the spinal cord, a specific dorsal root ganglion, and the sciatic nerve (separately) are available. Here, we provide detailed pictures and a schematic of the central and peripheral murine nervous system. More importantly, we outline a robust procedure to perform its dissection. The 30 min pre-dissection step allows isolating the intact nervous system within the vertebra with muscles free of viscera and skin. A 2-4 h dissection follows it under a micro-dissection microscope to expose the spinal cord and the thoracic nerves, and finally peel the whole central and peripheral nervous system off the carcass. This protocol represents a significant step forward in studying the anatomy and pathophysiology of the nervous system globally. For example, the dissected dorsal root ganglions from a neurofibromatosis type I mice model can be further processed for histology to unravel changes in tumor progression.

Late complications after Norwood stage 1 palliation: surgical strategies and a word of caution.

The current case represents one of the complications that may occur when inserting a stent in the left pulmonary artery after a previous Norwood procedure and in the presence of an aneurysmal neo-aorta and large Damus-Kaye-Stansel connection. We demonstrate the technique of a fourth sternotomy with reconstruction of the left pulmonary artery and the neo-aorta in a 12-year-old boy with a functional single ventricle who underwent all three previous stages of palliation of hypoplastic left heart syndrome.

Fetoscopic endoluminal tracheal occlusion with Smart-TO balloon: Study protocol to evaluate effectiveness and safety of non-invasive removal.

INTRODUCTION: One of the drawbacks of fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia is the need for a second invasive intervention to reestablish airway patency. The "Smart-TO" (Strasbourg University-BSMTI, France) is a new balloon for FETO, which spontaneously deflates when positioned near a strong magnetic field, e.g., generated by a magnetic resonance image (MRI) scanner. Translational experiments have demonstrated its efficacy and safety. We will now use the Smart-TO balloon for the first time in humans. Our main objective is to evaluate the effectiveness of prenatal deflation of the balloon by the magnetic field generated by an MRI scanner. MATERIAL AND METHODS: These studies were first in human (patients) trials conducted in the fetal medicine units of Antoine-Béclère Hospital, France, and UZ Leuven, Belgium. Conceived in parallel, protocols were amended by the local Ethics Committees, resulting in some minor differences. These trials were single-arm interventional feasibility studies. Twenty (France) and 25 (Belgium) participants will have FETO with the Smart-TO balloon. Balloon deflation will be scheduled at 34 weeks or earlier if clinically required. The primary endpoint is the successful deflation of the Smart-TO balloon after exposure to the magnetic field of an MRI. The secondary objective is to report on the safety of the balloon. The percentage of fetuses in whom the balloon is deflated after exposure will be calculated with its 95% confidence interval. Safety will be evaluated by reporting the nature, number, and percentage of serious unexpected or adverse reactions. CONCLUSION: These first in human (patients) trials may provide the first evidence of the potential to reverse the occlusion by Smart-TO and free the airways non-invasively, as well a safety data.

Feasibility and Safety of Robotic-Assisted Surgery for Rectal Cancer: Short-Term Outcomes of a Pilot Study with da Vinci Xi Platform During COVID-19.

Background: Colorectal cancer is a major cause of morbidity and mortality in the world. Approximately, one of three diagnosed colorectal cancers is a rectal cancer. Recent developments in the field of rectal surgery have promoted the use of surgical robots, which are of great need when surgeons face anatomical difficulties, such as a narrowed male pelvis, bulky tumor, or obese patients. This study aims to evaluate the clinical results of robotic rectal cancer surgery during the introduction period of a surgical robot system. Moreover, the period of the introduction of this technique coincided with the first year of the COVID-19 pandemic. Methods: Since December 2019, the Surgery Department of the University Hospital of Varna has become the newest and the most modern Robotic Surgery Center of Competence in Bulgaria, equipped with the most advanced da Vinci Xi surgical system. From January 2020 to October 2020 a total number of 43 patients have underwent surgical treatment, of which 21 had roboticassisted procedures and the rest - open procedures. Results: Patient characteristics were close between the studied groups. The mean patient age in robotic surgery was 65 years, as six of these patients were females, while in case of open surgery these values were to 70 and 6, respectively. Two thirds (66.7%) of the patients operated on with da Vinci Xi were with tumor stage 3 or 4 and approximately 10% had the tumor located in the lower part of the rectum. The median value of the operation time was 210 min, while the length of hospital stay was 7 days. These short-term parameters were not found to have a large difference in respect to the open surgery group. A significant difference is depicted for the number of lymph nodes resected and the blood loss, with both parameters demonstrating advantage for the robot-assisted surgery. The blood loss is more than twice less than the case of open surgery. Conclusions: The results confidently showed the successful introduction of the robot-assisted platform in the surgery department despite the limitations caused by the COVID-19 pandemic. This technique is expected to become the main choice of minimally invasive technique applied to all types of colorectal cancer surgery in the Robotic Surgery Center of Competence.