Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies

Background

Because of the diversity of aneurysm morphology, complicated arterial anatomy and hemodynamic characteristics, tailored surgical treatments are required for cases of individual complex middle cerebral artery (MCA) aneurysms.

Methods

During an 8-year period, 59 complex MCA aneurysms in 58 patients were treated microsurgically in our department. Complex aneurysms were defined as having large (10–24 mm in diameter) or giant (diameter?≥?25 mm) size or non-saccular morphology (fusiform, dissecting or serpentine).

Results

Direct clipping of the aneurysmal necks was achieved in eight patients, while reconstructive clipping was performed in 25 patients. Indirect aneurysm occlusion was performed in 25 cases, including trapping or resecting the aneurysm in four cases, trapping or resecting the aneurysm with extra-intracranial (EC) or intra-intracranial (IC) bypass in 21 cases and internal carotid artery (ICA) sacrifice with EC-IC bypass in one case. Forty-eight aneurysms (81.4 %) were completely obliterated. Graft patency was confirmed in 20 of 21 cases (95.2 %) with bypass. A recurrent aneurysm was detected in one case and a re-operation was performed. Two patients with Hunt-Hess grade IV aneurysms died during the perioperative period. Overall, 52 cases (88.1 %) had good outcomes (Glasgow Outcome Scale?≥?4) during the late follow-up period.

Conclusion

The surgical modality and strategy for treating complex MCA aneurysm are decided according to the morphology of the aneurysm, vascular anatomy and the hemodynamic characteristics of each case. Thus, we developed a new classification based on the angioarchitecture. Favorable outcomes can be achieved by treating complex MCA aneurysms with appropriate surgical modalities, strategies and techniques.     

Unruptured non-branching site aneurysms located on the anterior (dorsal) wall of the supraclinoid internal carotid artery: aneurysmal characteristics and outcomes following endovascular treatment

Background

This study was undertaken to evaluate the aneurysmal characteristics and clinico-radiological outcomes of unruptured non-branching site aneurysms located on the anterior (dorsal) wall of the supraclinoid internal carotid artery (ICA).

Methods

The data of 34 patients that underwent endovascular treatment for 36 unruptured ICA anterior wall aneurysms were reviewed. ICA anterior wall aneurysms were defined as aneurysms that projected superiorly from the anterior wall of the ICA ophthalmic (n?=?35) or communicating (n?=?1) segment on lateral angiograms, without any branch vessel relationship. In addition, aneurysmal characteristics and treatment outcomes were compared with those of 60 unruptured aneurysms originating from the posterior (ventral) wall of the ICA ophthalmic segment.

Results

Patients with an ICA anterior wall aneurysm frequently had a mirror aneurysm on the contralateral side (14.7?% versus 3.3?%) or another ICA aneurysm (35.3?% versus 15?%). Two of the 36 ICA anterior wall aneurysms exhibited ICA narrowing suggestive of dissection, and another five had dysplastic ICA dilatation around the neck. Stent-assisted embolization was more frequently performed for ICA anterior wall aneurysms (66.7?% versus 36.7?%) because of unfavorable dome/neck (mean, 1.21) and aspect (mean, 1.15) ratios, and because of microcatheter instability associated with superior aneurysmal projections against the abrupt curvature of the carotid siphon. Procedure-related thromboembolic complications occurred in three patients in the anterior aneurysm group, but no patient deteriorated clinically. Immediate radiological outcomes were more unfavorable for ICA anterior wall aneurysms (residual sac, 36.1?% versus 16.7?%). Nevertheless, rates of recanalization (2.9?% versus 5.2?%) and progressive occlusion (24.7?% versus 8.1?%) during follow-up slightly favored ICA anterior wall aneurysms. Two stent-treated ICA anterior wall aneurysms developed asymptomatic ICA steno-occlusion (8.3?%).

Conclusions

Stent-assisted embolization is safe and effective for the treatment of unruptured ICA anterior wall aneurysms exhibiting unfavorable aneurysmal geometries and projections for coil embolization.     

Posterior auricular artery as an alternative donor vessel for extracranial-intracranial bypass surgery

Background

Sometimes the superficial temporal artery (STA) is not available for an extracranial-intracranial (EC-IC) bypass procedure. An alternative vessel for an EC-IC bypass is the posterior auricular artery (PAA) if it extends to the temporoparietal area with a diameter large enough. We assessed the prevalence of an appropriate PAA as an alternative donor vessel and report three illustrative cases in which the PAA was used for EC-IC bypass surgery.

Methods

A literature search was performed on the use of the PAA as a donor vessel for bypass surgery. Secondly, a prospective database of bypass surgeries was reviewed to calculate the prevalence of a PAA with a diameter of at least 1 mm in the parietotemporal area. Finally, three illustrative cases are reported that describe various indications for the revascularisation procedures with their clinical, surgical and imaging features.

Results

Two articles have previously described the use of the PAA for bypass surgery and their results are summarised. The prevalence of a PAA that would be appropriate for an EC-IC bypass in patients with intracranial vascular pathology is 5.7 %. The presented cases demonstrate that the PAA can be successfully used for EC-IC bypass surgery with good flow velocities and patency.

Conclusions

The PAA is a rarely described as an appropriate donor vessel for an EC-IC bypass. Its prevalence is 5.7 % and it can successfully be used as an alternative donor vessel. The awareness among cerebrovascular surgeons about the presence of a PAA and knowledge about its anatomy may be valuable.     

Microsurgical management of distal anterior cerebral artery aneurysms: from basic to complex, a video review of four cases

Background

Distal anterior cerebral artery (DACA) aneurysms represent 2–9 % of intracranial aneurysms. They are often more amenable to surgical rather than endovascular treatment due to the size of parent vessels.

Method

We illustrate surgical approaches for DACA aneurysms arising from different segments of the anterior cerebral artery. Cases range from simple unruptured aneurysms to complex ruptured aneurysms requiring reconstruction and intracranial bypass.

Conclusion

The interhemispheric approach typically provides an adequate surgical corridor for surgical clipping of DACA aneurysms. Patient positioning, image guidance, and preoperative angiography help maximize safety and efficacy of surgery.     

Traumatic intracranial aneurysms due to blunt brain injury—a single center experience

Background

Traumatic intracranial aneurysms (TICAs) have previously been described in literature. However, the evidence of TICAs secondary to blunt brain injury have not been elucidated well, with most of the conclusions coming from isolated case reports. We have attempted to examine the epidemiology, classification, clinical presentation, therapeutic modalities, and outcomes of TICAs with our series of patients at the neurosurgery department of Xuanwu Hospital, China.

Methods

We reviewed our aneurysm database from January 1, 2005 to December 31, 2011. In particular, patients with TICAs secondary to blunt brain injury were reviewed. Variables assessed included age, sex, causes of blunt brain injury, skull fracture, location, classification, clinical presentation, time elapsed to arrive at diagnoses, treatment, and eventual outcome. Based on our assessment, we arrived at a modified classification scheme to categorize these aneurysms.

Results

We reviewed 2335 patients with cerebral aneurysm from January 1, 2005 to December 31, 2011. Of these, 15 patients (0.64?%) with traumatic aneurysms secondary to blunt brain injury were identified.Motor vehicle accidents (MVA) were observed to be the most common cause of injury (10 patients, 66.7 %), followed by TICAs sustained after falling down (5 patients, 33.3?%). The most common symptom at presentation was epistaxis (6 patients, 40?%), followed by ophthalmic problems (6 patients, 40?%), with both presentations seen in 1 patient. The most common diagnostic modality used was DSA in 12 patients (80?%) followed by CTA in 2 patients (13.3?%). Infraclinoid TICAs were seen in 9 patients (60?%), whereas supraclinoid TICAs were seen in 5 patients (33.3?%), with perifalx TICAs seen in 1 patient. Endovascular intervention therapies were performed in 11 patients (73.3?%), bypass surgery and trapping in 2 (13.3?%), transnasal endoscopic approach in combination with balloon assisted in 2 patients. At discharge, 2 patients had poor clinical outcomes (13.3?%), 5 had fair (33.3?%),and 8 resulted with good outcomes (53.3?%).

Conclusions

TICAs arising secondary to blunt brain injury account for 0.64?% of all cerebral aneurysms. Infraclinoid, supraclinoid ICA and perifalx TICAs are the most common aneurysms arising from blunt brain injury. Our study further shows that traumatic patients presenting with recurrent epistaxis, oculomotor nerve palsy, and delayed intracranial hemorrhage should receive cerebroangiography as soon as possible. An early diagnosis and proper treatment could prove to be helpful in terms of improving final clinical outcome.     

Management of giant intracranial ICA aneurysms with combined extracranial-intracranial anastomosis and endovascular occlusion

Nine patients with giant internal carotid artery (ICA) aneurysms (greater than 2.5 cm in diameter) were subjected to a combined extracranial-intracranial (EC-IC) bypass procedure and endovascular ICA occlusion during 1987 and 1988. The procedures were performed under one anesthetic. In all cases the collateral circulation had been judged insufficient on the basis of a strict preoperative testing protocol including: cerebral panangiography, electroencephalography, somatosensory potential recording, and cerebral blood flow monitoring during manual compression of the ICA in the neck. There were four intracavernous ICA aneurysms, four carotid-ophthalmic artery aneurysms, and one supraclinoid ICA aneurysm. All patients showed symptoms and signs of compression of the surrounding nervous structures. In the five cases of intradural lesions, the artery was occluded at the level of the aneurysm neck, so the ophthalmic artery had to be occluded. There was, nevertheless, no case of worsening of vision following surgery, and all nine patients showed significant improvement following the combined procedure. A combined EC-IC bypass procedure and endovascular ICA occlusion allows for immediate verification of the surgical results and appears to be a worthwhile method for treating giant intracranial aneurysms.     

What are the treatment options for blister-like aneurysms?

Treatment of blood blister-like aneurysms (BBAs) of the supraclinoidal internal carotid artery (ICA) is challenging and the optimal treatment is yet to be defined. The treatment options for ICA BBAS are microsurgery, endovascular therapy, or a combination of the two. The microsurgical armamentarium consists mainly of direct aneurysm clipping with or without protective EC-IC bypass, clip-wrapping, or trap ligation with ICA sacrifice with or without EC-IC bypass. The endovascular treatment options are mainly endovascular ICA ligation, multiple overlapping stents (≥ 3) with or without coiling, covered stents, or flow diverters. In four recent meta-analyses of BBAs, neither microsurgical nor endovascular therapy had an impact on clinical outcome in multivariate analysis. Microsurgery offered aneurysm obliteration rates superior to endovascular techniques, but came at a higher risk of intraoperative bleeding. Endovascular therapy increased the likelihood of a second treatment, conversion to another treatment modality, and incomplete aneurysm obliteration. In this review, we discuss pros and cons of the above approaches while adding our own viewpoints to the discussion.     

Intracranial aneurysms in patients with internal carotid artery occlusion: management and outcome in 22 cases

Background

There is little information about clinical characteristics, management, and outcome of patients with intracranial aneurysms and internal carotid artery occlusion. We will describe clinical characteristics, treatment and outcome of patients with coexistent internal carotid artery occlusion and intracranial aneurysms.

Methods

We conducted a retrospective chart review of 22 patients (eight males and 14 females) with coexistent internal carotid artery (ICA) occlusion and intracranial aneurysms.

Results

This series includes 14 females and eight males with a mean age of 63 years (range, 49 to 80). These patients harbored a total of 35 aneurysms, which were located on the same side of the ICA occlusion in five cases, on the contralateral side in 20 cases, while in ten cases the aneurysm had a midline location (AcomA 9, Basilar tip 1). Treatment consisted of surgery for eight aneurysms and endovascular embolization for 13 aneurysms. No invasive treatment was recommended for 14 aneurysms (eight patients with single aneurysm). No permanent perioperative or periprocedural complications occurred in the selected group of patients undergoing invasive treatment. At a mean follow-up of 57?months (range, 3–203), no patient had a subarachnoid hemorrhage and three patients had died of causes not related to the aneurysm.

Conclusion

Surgical and endovascular treatment can be accomplished safely in selected patients with coexistent ICA occlusion and intracranial aneurysms. Conservative treatment is a valid alternative, especially in elderly patients or in patients with very small aneurysms, especially if not located along the collateral pathway.     

Clinical management of renal cell carcinoma with venous tumor thrombus

Objectives

Venous invasion is common in advanced renal cell carcinoma (RCC) due to the unique biology of this cancer. The presence of a tumor thrombus often makes clinical management challenging. In this review, we detail specific preoperative, perioperative, and surgical strategies involving the care of the complex kidney cancer patient with venous tumor involvement.

Methods

We performed a comprehensive review of selected peer-reviewed publications regarding RCC tumor thrombus biology, medical and surgical management techniques, and immediate and long-term outcomes.

Results

The perioperative management may require special imaging techniques, preoperative testing, very recent imaging, and consultation with other surgical services. There are various approaches to these patients as the clinical presentation, stage of disease, primary tumor size, level of thrombus, degree of venous occlusion, presence of bland thrombus, and primary tumor laterality influence management. Select patients with metastatic disease can do well with cytoreductive nephrectomy and thrombectomy. Those with localized disease have a high risk of recurrence; however, some patients can exhibit durable survival with surgery alone. The evolving surgical and medical treatments are discussed.

Conclusions

Even when these surgeries are performed in high volume centers, significant perioperative complications are common and greater complications are seen with higher thrombus extent. If surgery is attempted, it is important for urologic oncologists to follow strict attention to specific surgical principles. These general principles include complete vascular control, avoidance of thrombus embolization, close hemodynamic monitoring, and institutional resources for caval resection/replacement and venous bypass if necessary.     

Focused opening of the sylvian fissure for microsurgical management of MCA aneurysms

Background

A wide sylvian opening, with either a proximal or distal start, has been standard for microsurgical management of middle cerebral artery (MCA) aneurysms. However, extensive sylvian dissection is potentially associated with increased incidence of iatrogenic injury to the brain and neurovascular structures. The aim of the present study was to describe the technique of focused opening of the sylvian fissure for microsurgical management of MCA aneurysms with additional tips on handling difficulties which may be encountered with this technique.

Method

A 3D image-based anatomic orientation, clipping field–focused surgical planning, slack brain, and high magnification are the basic requirements for this approach. A 10–15 mm sylvian opening is placed so that it allows safe access and a good surgical view of the MCA aneurysm clipping field. Under proximal control of the MCA, the aneurysm neck can be dissected and clipped effectively and safely, in this small surgical field.

Results

The presented technique has been developed and refined by the senior author during the surgery of 1,097 aneurysms over the last 13 years. It has proved to be safe, and effective for clipping of both ruptured and unruptured MCA aneurysms. Its greatest advantages are a shorter operative time and less brain and vessel manipulation compared to more extensive approaches.

Conclusion

The focused sylvian opening is a less-invasive alternative to the classical wide sylvian opening for the microsurgical management of most MCA aneurysms.     

Could the types of paraclinoid aneurysm be used as a criterion in choosing endovascular treatment? Neuro-radiologists’ view

Background

The type of paraclinoid aneurysm has been used to decide management methods. Our aim was to assess the relation of the types of paraclinoid aneurysms and outcomes after endovascular treatment and the efficiency of present endovascular techniques.

Methods

A retrospective analysis was performed on patients with saccular paraclinoid aneurysms that had more than 6 months of angiographic follow-up or recurrence within this period after endovascular treatment from January 2009 to December 2010. Paraclinoid aneurysms were classified into two types and then further into four subtypes by a modified classification method. A classification-based microcatheter shaping method was used in the procedure. The significant risk factors of angiographic results were determined through correlation analysis and logistic regression analysis by SPSS 17.0.

Results

There were 64 aneurysms in 56 patients; 28 aneurysms belonged to Type I, while 36 were Type II. A total of 12 aneurysms were managed with coil embolization, and 52 with stent-assisted coiling technique. Our classification-based microcatheter shaping method was successful in all cases. Coil protrusion happened in two cases without severe complications. Recurrence were found in 13 (20.3 %) aneurysms followed up at 12.42?±?3.78 (mean±SD) months after treatment. The correlation between aneurysm types and immediate angiographic result or follow-up angiographic results did not reach statistical significance. Aneurysm types were not the risk factor of recurrence.

Conclusions

The types of paraclinoid aneurysm had not been significant correlated with outcomes of endovascular treatment. Fundus size was the significant risk factor of recurrence after endovascular treatment. A classification-based microcatheter shaping method may be used in endovascular treatment paraclinoid aneurysms. The present endovascular techniques are safe and effective.     

Recovery from oculomotor nerve palsy due to posterior communicating artery aneurysms: results after clipping versus coiling in a single-center series

Background

Oculomotor nerve palsy (ONP) is a common clinical manifestation of ruptured or unruptured posterior communicating artery (PcomA) aneurysms. Although microsurgical clip ligation has been proven a safe and durable treatment, endovascular management is emerging as an increasingly popular alternative. The aim of our study is to compare the recovery rate from ONP and assess the safety and long-term durability of both techniques.

Methods

We have reviewed the retrospective data concerning twenty-two patients treated at our institution between 2004 and 2012 for PcomA aneurysms with ONP. Seven patients were operated on via a standard pterional approach, and fourteen were treated by endovascular occlusion with coils. One patient was managed conservatively. Pre-treatment and post-treatment severity of ONP was recorded, as well as the duration of symptoms before admission and treatment-related complications.

Results

All seven patients who underwent surgery improved, with six total recoveries and one partial recovery. Among the fourteen patients treated by embolization, thirteen initially recovered, but long-term follow-up revealed three cases of exacerbation of ONP after refilling of the aneurysms. Two of them were clipped, and one embolized. Also, one partially resolved patient underwent a second embolization. No severe complications occurred in either group.

Conclusions

Despite the small number of patients, our study suggests that both surgical clipping and embolization are safe and effective methods in regards to functional recovery (complete ONP recovery in about 85 % of the cases). However, coiling may lead to delayed recurrence of third cranial nerve (CN) palsy at long-term follow-up, requiring additional treatment.     

Multiple reimplantation technique for treatment of complex giant aneurysms of the middle cerebral artery: technical note

Background

Giant middle cerebral artery (MCA) aneurysms are among the most challenging neurovascular lesions, especially when the M2 and M3 branches are incorporated into the aneurysm. Here we report on two cases with complex MCA aneurysms, in which double and triple arterial reimplantation of the efferent vessels into a saphenous vein graft (SVG) was applied to reconstruct the MCA tree, allowing final trapping of the aneurysm.

Methods

In the first case, a 41-year-old woman presented with a partially thrombosed giant MCA aneurysm including three efferent branches. Two superior trunks were disconnected and reimplanted onto an SVG fed by the external carotid artery (ECA). Following anastomosis between the SVG and the inferior trunk, the aneurysm was trapped. The second case is a 67-year-old man with recurrent giant MCA aneurysm incorporating two efferent M2 branches. First, the superior trunk was reimplanted onto an SVG, then the SVG was anastomosed to the inferior trunk. Finally the afferent M1 was clipped. Intraoperative indocyanine green (ICG) videoangiography (FLOW 800) was used for studying bypass patency.

Results

In both cases, successful bypass patency was demonstrated by ICG videoangiography. Postoperative digital subtraction angiography (DSA) confirmed bypass patency. The first case was discharged without any neurological deficit. The second case suffered from bleeding due to refilling of the aneurysm via the inferior M2. An additional clip was placed on the inferior M2 in a second step. The patient was discharged with weakness of the left arm.

Conclusion

Reconstructing an MCA bifurcation or trifurcation combining multiple arterial reimplantation is effective for treatment of selective cases of complex MCA aneurysms.     

The outcome of a surgical protocol based on ischemia overprotection in large and giant aneurysms of the anterior cerebral circulation

Aiming to define the optimal treatment of large and giant aneurysms (LGAs) in the anterior circulation, we present our surgical protocol and patient outcome. A series of 42 patients with intracavernous LGAs (n?=?16), paraclinoid (C2) LGAs (n?=?17), and peripheral (middle cerebral artery—MCA or anterior cerebral artery—ACA) LGAs (n?=?9) were treated after bypass under motor evoked potential (MEP) monitoring. Preoperatively, three categories of ischemic tolerance during internal carotid artery (ICA) occlusion were defined on conventional angiography: optimal, suboptimal, and insufficient collaterals. Accordingly, three types of bypass: low flow (LFB), middle flow (MFB) and high flow (HFB) were applied for the cases with optimal, suboptimal, and insufficient collaterals, respectively. Outcome was evaluated by the Glasgow Outcome Scale (GOS). All patients had excellent GOS score except one, who suffered a major ischemic stroke immediately after surgery for a paraclinoid lesion. Forty-one patients were followed up for 87.1?±?40.1 months (range 13–144 months). Intracavernous LGAs were all treated by proximal occlusion with bypass surgery. Of paraclinoid LGA patients, 15 patients had direct clipping under suction decompression and other 2 patients with recurrent aneurysms had ICA (C2) proximal clipping with HFB. MEP monitoring guided for temporary clipping time and clip repositioning, observing significant MEP changes for up to 6 min duration. Of 9 peripheral LGAs patients 7 MCA LGAs had reconstructive clipping (n?=?4) or trapping (n?=?3) with bypass including LFB in 3 cases, MFB in 1 and HFB in 1. Two ACA LGAs had clipping (n?=?1) or trapping (n?=?1) with A3-A3 bypass. The applied protocol provided excellent results in intracavernous, paraclinoid, and peripheral thrombosed LGAs of the anterior circulation.     

Surgical management of vertebral and basilar artery aneurysms: a single center experience in 41 patients

Objective

To study an effective method for surgical management of vertebral and basilar artery aneurysms.

Methods

Forty-one patients with 43 aneurysms of the vertebral and basilar arteries were managed by microsurgical clipping. Cerebral angiography revealed basilar apex aneurysms in 17 patients, basilar trunk in six patients, vertebrobasilar (VB) junction aneurysms in three patients and vertebral aneurysms in 15 patients. One patient had two basilar aneurysms, and another had bilateral vertebral artery aneurysm.

Surgical technique

We used a pterional approach in basilar apex aneurysms (n?=?17 patients), orbitozygomatic and its variants in upper basilar trunk aneurysms (n?=?2 patients), combined petrosal and far-lateral approach in mid basilar trunk aneurysms (n?=?4 patients), far-lateral and transcondylar approach for the aneurysms at VB junction (n?=?3 patients) and transcondylar approach for the vertebral aneurysms (n?=?15 patients). Bypass graft was performed in 14 patients with fusiform and wide neck aneurysms, to prevent potential cerebral ischemia due to prolonged temporary occlusion or possibility of intraoperative parent artery sacrifice.

Results

Neurological outcomes were measured on the basis of Glasgow Outcome Score (GOS). The rate of back-to-normal life after surgery in basilar tip aneurysm, basilar trunk aneurysms, VB junction aneurysms and vertebral artery aneurysms was 15/17 (82.5 %), 5/6 (83 %), 3/3 (100 %) and 14/15 (93.3 %), respectively. Thirty-six (87.8 %) patients had uneventful postoperative courses. Two patient with basilar apex aneurysm suffered severe neurological deficits related to midbrain ischemia, two patient with occipital artery (OA) graft bypass had postoperative partial lower cranial nerve palsy, and one death with basilar trunk aneurysm occurred after the 20th day of surgery. Thirty-nine patients accepted postoperative digital subtraction angiography (DSA) and eight patients accepted computed tomography (CT) angiogram, whereas two patient denied either one. All the images demonstrated afferent and efferent vessels without aneurysm in situ. Out of 14 patients with graft bypass, 11 patients on cerebral angiographies disclosed the aneurysm clip and the graft bypass patency, one patient on angiography had unidentified graft bypass patency but no symptom related to the graft bypass patency, and two patients denied the postoperative cerebral angiographies. In 40 patients with a mean follow-up of 3.4 years, 37 patients had good outcome, two patients needed assistance for daily living, and one death occurred due to brainstem infarction related to surgery.

Conclusion

Selection of proper cranial base approach with adequate exposure is effective in clipping VB aneurysms, minimizing the postoperative complications. Graft bypass may avoid parent artery sacrifice and its branches occlusion in patients with fusiform and wide neck aneurysms.     

Demographics and outcomes at American Society for Metabolic and Bariatric Surgery Centers of Excellence

Introduction

Surgery is currently an effective long-term therapy for morbid obesity and its complications. A variety of surgical procedures can now offer durable and safe weight control as well as previously unrealized full remission of costly comorbidities. This is a preliminary investigation of patient characteristics and outcomes at Bariatric Surgery Centers of Excellence^® (BSCOE^®) hospitals.

Methods and procedures

Data were analyzed from 235 American Society for Metabolic and Bariatric Surgery (ASMBS) BSCOE^® hospitals receiving Full Approval status from August 2005 to May 2007. Metrics for the 66,339 bariatric surgeries performed at these hospitals included type, volume and distribution of various bariatric surgical procedures performed at each hospital, patient demographics, payer information, and adverse outcomes.

Results

Data from these analyses demonstrate significant differences in terms of surgical procedure selection (laparoscopic gastric bypass 61%), patient demographics (females 83%, White 60%, mean age 43 years) and type of payer (private insurance 78%), and adverse outcomes (readmission 5%, re-operation 2%, mortality 0.36%).

Conclusions

The collective performance of ASMBS BSCOE hospitals in bariatric outcomes of readmissions, re-operations, and mortality are equivalent to, or more favorable, than currently reported outcomes. However, risk assessment and risk adjustment of the patients and each of the bariatric procedures will be necessary to appropriately evaluate these rates.     

Robot-assisted triple neurectomy for iatrogenic inguinal pain: a technical note

Background

Painful neuromas are a relatively common complication of hernia and abdominal wall surgery.

Objective

Surgical neurectomy has the potential to to provide durable relief for chronic pain; however, current surgical approaches are not without morbidity or anatomical challenges.We sought a surgical alternative.

Methods

In the treatment of a case of incapacitating inguinal pain, we performed an anterior transperitoneal approach using a surgical robot.

Results

This approach was facile and provided elegant anatomical visualization.

Conclusion

This case describes the first known robot-assisted laparoscopic triple neurectomy and details a simplified, transperitoneal approach.     

Blood blister-like aneurysms at nonbranching sites of the internal carotid artery

OBJECT: The clinical features of blood blister-like aneurysms (BBAs) that arise at nonbranching sites of the internal carotid artery (ICA) differ from those of saccular aneurysms. In this study, the authors attempt to describe optimal treatments for BBAs, which have yet to be clearly established. METHODS: Ten of 483 patients with aneurysmal subarachnoid hemorrhage who had been seen at the authors' institution between March 2001 and June 2005 had intraoperatively confirmed BBAs at nonbranching sites of the ICA. All ten patients were women between the ages of 37 and 64 years (mean age 49.3 years); five had a history of hypertension. The BBAs were localized to the right side of the ICA in seven cases. All patients were successfully treated; clipping was undertaken in six, clipping combined with wrapping in three, and trapping in one. These methods were used in conjunction with various other surgical techniques such as brain relaxation by draining cerebrospinal fluid, anterior clinoidectomy, exposing the cervical ICA, gentle subpial dissection (for aneurysms that adhered to the frontal lobe), complete trapping of the ICA before clipping, and protecting the brain. Clip slippage occurred at the end of dural closing in two cases; the aneurysm was completely obliterated using multiple clips combined with ICA stenosis in one of these cases and ICA trapping with good collateral flow in the other. An excellent clinical outcome was achieved in eight patients, whereas two patients were disabled from massive vasospasm. The authors retrospectively reviewed radiological and surgical data in all cases to determine which treatment methods produced a favorable outcome. CONCLUSIONS: Blood blister-like aneurysms located at nonbranching sites of the ICA are difficult to treat. Preoperative awareness and careful consideration of these lesions during surgery can prevent poor clinical outcomes.