The neurosurgical treatment of epilepsy

Despite the new advancements in antiepileptic drug development, thousands of people with epilepsy will remain intractable to medication. For a considerable proportion of these people, epilepsy surgery is a consideration for better control of their seizures. Resective surgery is now standard practice for patients with medication-refractory epilepsy. Temporal lobectomy continues to be the most common surgery performed. Once patients fail 2 to 3 optimal trials of antiepileptic medication, further drug therapy offers a minimal number of patients freedom from seizures. In contrast, temporal lobectomy in carefully selected patients may result in seizure-free outcomes in more than 70% to 90% of patients with intractable seizures. As technology and drug availability increases in the new millennium, it is important for the primary care physician to be aware of epilepsy surgery as a means to treat patients with antiepileptic drug-refractory epilepsy. Arch Fam Med. 2000;9:1142-1147     

冠心病介入诊疗术并发症的护理要点

目的为促进冠心病介入诊疗术后的康复寻找较好的护理措施。方法对368例住院冠心病介入诊疗患者所发生的并发症,进行分析处理。结果冠心病介入诊疗术并发症的发生率为:心律失常9.2%,其中室早10例,室上速13例,严重缓慢性心律失常8例,室颤2例。心绞痛5.7%,血管并发症4.9%,其中10例为穿刺部位血肿,2例出血,6例为假性动脉瘤。迷走神经反射性低血压0.8%,发热1.6%,排尿困难0.8%。结论强调对患者及家属做好卫生知识宣教,掌握有关冠心病介入诊疗术的相关知识,以增加患者接受诊疗及术前、术后护理的顺应性,从而减少并发症的发生。     

Partial hepatectomy for benign or malignant liver diseases; experience in 94 patients

In this retrospective study, we analyse the results of 94 partial liver resections performed between 1972 and January 1989. The resections were performed for malignant (48 patients) and benign (46 patients) liver tumours. Nine patients (9.6%) died of resection-related complications. Mortality was significantly lower in the patients with resections for benign liver tumours (2.2%) compared with patients with resections for malignant liver tumours (16.7%) (p less than 0.05). In the patients who survived the first 30 days, complications occurred in 25.9%. The 5-year survival of patients with a primary malignant liver tumour (57%) is significantly (p = 0.05) better than in patients with a secondary malignant liver tumour (19%). From this study we conclude that partial liver resections for primary or secondary liver tumours can be performed with an acceptable mortality and morbidity, and should be the therapy of choice for selected patients.     

Retrospective application of the performance indicator 'hip fracture: operate within 24 hours' in 217 patients treated at the University Medical Centre Utrecht in 2000-2003: reduction in postoperative pneumonia but not mortality

OBJECTIVE: To evaluate whether patients with hip fracture who undergo surgery within 24 hours--which has been propagated as an indicator of quality care--is associated with a reduced risk of mortality and complications, compared with later surgery. DESIGN: Retrospective status study based on a prospectively designed electronic medical record. METHOD: Data were collected on patients aged > or =60 years who were admitted to the University Medical Centre Utrecht, the Netherlands, between 1 January 2000 and 31 December 2003 for hip fracture. Outcomes were compared in patients who underwent surgery within 24 hours and those who underwent surgery after more than 24 hours. The primary outcome measure was mortality (in-hospital, after 3 months, 12 year and 3 years after discharge). Secondary outcome measures were postoperative complications, postoperative duration ofhospital stay and admission to long-term care facilities. We corrected for age, gender and pre-existing comorbidity. RESULTS: A total of 217 patients were included. In the 150 patients who underwent surgery within 24 hours, the mean age was 80.5 years, 75% were female and 28% were class III or IV according to the American Society of Anesthesiologists (ASA). In the 67 patients who underwent surgery after more than 24 hours, the mean age was 80.9 years, 82% were female, and 49% were ASA class III or IV. After correcting for published risk factors, there was no relationship between the timing of surgery and mortality. Fewer patients treated within 24 hours developed pneumonia postoperatively. In this study population, the only risk factor for mortality was the preoperative condition of the patient. CONCLUSION: Postoperative pneumonia occurred less frequently in patients with hip fracture who underwent surgery within 24 hours. Postoperative mortality was related to poor patient condition but not the timing of surgery. Early surgery should be avoided in patients with severe comorbidity who are not optimally prepared for surgery.     

比较研究全肩关节镜与关节镜辅助下切开治疗肩袖损伤的效果

目的:对比研究全肩关节镜和关节镜辅助下切开治疗肩袖损伤的临床效果.方法:选取2018年1月~2019年1月本院接收的肩袖损伤患者90例,将于关节镜辅助下实施切开治疗的45例设为A组,将开展全肩关节镜切开术的45例设为B组,对比两组患者的临床治疗结果.结果:治疗后,B组患者的UCLA评分与ASES评分均明显高于A组,P<0.05;B组患者的VA S评分明显低于A组,P<0.05;B组患者的术后并发症发生率4.44%与A组的6.67%则并无明显差异,P>0.05.结论:相较于关节镜辅助下切开治疗,肩袖损伤患者采用全肩关节镜切开治疗的疗效更为显著,可有效改善患者的关节功能与疼痛症状.     

Transhiatal esophagus resection without thoracotomy for carcinoma: complications, hospital mortality and prognosis in 115 patients

OBJECTIVE: To evaluate the short-term and long-term clinical outcome of transhiatal oesophagectomy without thoracotomy for cancer. DESIGN: Retrospective. METHODS: In the period January 1993-August 1996, 115 patients underwent a transhiatal oesophagectomy with curative intent for adenocarcinoma or squamous cell carcinoma of the middle or distal oesophagus or oesophagogastric junction. There were 87 men and 28 women with a median age of 65 years (range: 37-83). Median duration of postoperative follow-up was 27 months (range: 1-74) for all patients, and 45 months (range: 30-74) for those alive at final follow-up. RESULTS: No emergency thoracotomies were necessary. In-hospital mortality was 3.5% (4 patients). Vocal cord dysfunction (24%) and pulmonary complications (23%) were the most frequent early postoperative complications. Clinical leakage of the cervical anastomosis occurred in 8 patients (7%). Forty per cent developed a benign anastomotic stricture which was treated by (repeated) endoscopic dilatation. A microscopically radical resection was achieved in 73% of the patients. Overall survival was 45% at 3 years. CONCLUSION: Transhiatal oesophagectomy without thoracotomy can be considered a safe procedure for resectable cancer of the midoesophagus, the distal oesophagus or the oesophagogastric junction. Long-term oncological treatment results were in line with the data reported for oesophageal resections via a transthoracic approach.     

Radiofrequency catheter ablation for treating children with cardiac arrhythmias: favourable results after a mean of 4 years

OBJECTIVE: Analysis of long-term results with radiofrequency catheter ablation (RF ablation) in children. DESIGN: Retrospective. METHOD: Data were analysed from all 118 paediatric patients < or =18 years old who underwent RF ablation at the Leiden University Medical Centre (LUMC), the Netherlands, during the period 1 December 1992-31 May 2004. RESULTS: The group consisted of 6o boys and 58 girls with a mean age of 12.7 years (SD: 4.6). They underwent 140 RF ablation procedures for 122 disorders. Indications for RF ablation were: failure or side-effects of antiarrhythmic medication (45%), patient/parent choice (45%), cardiomyopathy or life-threatening arrhythmia (8%), and impending surgery for a congenital heart defect (2%). The mean follow-up interval was 4 years (SD: 3.2; range: 1.2 months-11.3 years). The final total success rate for RF was 93% (n = 110). 19 patients (16%) underwent a total of 22 repeat procedures. Recurrences occurred after a mean period of 2.3 months (SD: 2.5) following successful RF ablation. Major complications (2nd degree AV block) occurred in 2 patients. During follow-up, no evidence was found of new arrhythmias or of coronary artery lesion development as the result ofRF ablation. There was no difference between the < 10 years of age group and the > or = 10 years of age group in terms of final success rate (93% vs. 93%; p = 0.914) and complication rate (3% vs. 7%, p = 0.680). CONCLUSION: The long-term outcome of paediatric patients who underwent RF ablation was good. RF ablation in young children (< 10 years) was found to be safe and effective. These results demonstrate that it is also possible to curatively treat this group of patients with RF ablation in specialized centres.     

Early neurologic complications following coronary bypass surgery

BACKGROUND: Coronary artery bypass surgery is associated with central and peripheral nervous system complications in the period following surgery. Recognising these complications may help in their prevention or early treatment. METHODS: We reviewed medical records of all the patients who underwent coronary artery bypass surgery at our institution over a period of two years. We studied their risk factors, reasons for surgery, operative variables, and post operative neurologic complications. RESULTS: Of the 587 coronary artery bypass surgeries performed at our centre over a two year period. We found that 2.04% of these patients developed neurologic complication in the two weeks following the surgery. Fifty percent of these patients suffered from cerebrovascular insults and 50% suffered from cognitive decline. No patients in this group developed seizures or peripheral nerve lesions. Patients with renal failure, carotid stenosis, history of cerebral strokes, and redo coronary bypass surgery were more predisposed to develop neurologic complications after bypass surgery. Furthermore, a longer stay in the coronary care unit and the development of arrhythmias predisposed patients to neurologic complications. Mortality for patients who developed neurologic complications post bypass surgery ranged between 16.7% and 33.4%. CONCLUSIONS: Around 2% of patients who undergo coronary artery bypass surgery develop neurologic complications in the period directly after the surgery. Patients with previous history of cerebral, coronary, or carotid disease are more predisposed for such complications, as well as patients who spend more time in the intensive units after the surgery.     

The medical management of epilepsy

With many new medications on the market and new data about the various side-effects of antiepilepsy drugs (AEDs), the medical management of epilepsy can seem unnecessarily complicated for the non-specialist. The process can be thought of taking place in 7 steps: 1) assessing the need for medications; 2) defining the seizures and classifying the epilepsy syndrome; 3) knowing which medications are best used in which syndromes; 4) taking into account patient priorities when choosing a medication, such as cotreatment or avoidance of neurobehavioral issues and weight loss or gain; 5) considering other life issues, such as planning a pregnancy and breastfeeding; 6) choosing a maintenance dose and deciding when to consider a change to another medication or to use dual therapy; and 7) if seizure-free, which patients to consider AED reduction or withdrawal. The goal is simply, no seizures and no side-effects. Seizure freedom is an important goal to reduce injury, mortality and improve quality of life. Improving tolerability is equally as important, as both acute and chronic side-effects of AEDs can be as disabling as seizures themselves.     

Post-oesophagectomy early enteral nutrition via a needle catheter jejunostomy: 8-year experience at a specialist unit

BACKGROUND AND AIMS: The purpose of this study was to prospectively evaluate post-operative jejunostomy feeding in terms of nutritional, biochemical, gastrointestinal and mechanical complications in patients undergoing upper gastrointestinal surgery for oesophageal malignancy. METHODS: The study included 205 consecutive patients who underwent oesophagectomy for malignancy. All patients had a needle catheter jejunostomy (NCJ) inserted at the conclusion of laparotomy. Patients were followed prospectively to record nutritional intake, type of feed administered, rate progression, tolerance, weight changes and complications either mechanical, biochemical or gastrointestinal. RESULTS: Ninety-two per cent of patients were successfully fed exclusively by NCJ post-oesophagectomy, and 94% of patients were tolerating a maintenance regimen of 2000 ml feed over 20 h by day 2 post-operatively. Patients spent a median of 15 days on jejunostomy feeding post-surgery (range 2-112 days); however, 26% required prolonged jejunostomy feeding (>20 days). Minor gastrointestinal complications were effectively managed by slowing the rate of infusion, or administering medication. Three (1.4%) serious complications of jejunostomy feeding occurred, all requiring re-laparotomy, one resulting in death. NCJ feeding was extremely effective in preventing severe post-operative weight loss in the majority of oesophagectomy patients post-op. However, oral intake was generally poor at discharge with only 65% of requirements being met orally. Sixteen patients (8%) patients required home jejunostomy feeding. By the first post-operative month, a further 6% (12) patients were recommenced on jejunostomy feeding. CONCLUSION: NCJ feeding is an effective method of providing nutritional support post-oesophagectomy, and allows home support for the subset that fail to thrive. Serious complications, most usually intestinal ischaemia or intractable diarrhoea, are rare.     

Complications within 30 days following placement of a carotid stent with cerebral protection in patients with considerable symptomatic carotid stenosis; Erasmus MC, Rotterdam, 1999-2004

OBJECTIVE: To describe the complications that occur within 30 days following the placement of a stent in the carotid artery in patients with considerable symptomatic carotid stenosis. DESIGN: Retrospective. METHOD: Data were collected on 98 patients who received a carotid stent due to symptomatic carotid stenosis of > or = 70% of the lumen at the Erasmus MC, Rotterdam, the Netherlands, in the years 1999-2004. A filter, distal occlusion balloon or the Parodi anti-embolism system was used to prevent cerebral embolism. Outcome measures were complications within 30 days following intervention. RESULTS: Four patients were excluded in the period between diagnosis and stenting. Major complications occurred in 3 patients: 1 died due to cerebral haemorrhage and 2 experienced cerebral infarction. Transient neurological complications occurred in 4 patients who recovered completely. Dissection of the renal artery occurred in 1 patient, which necessitated a stent. Vascular damage of the internal carotid artery was not observed in any patient. The 3 major adverse events and 3 of the 4 minor adverse events occurred in the first 47 patients treated. None of the last 47 patients treated developed major adverse events.     

Hypoalbuminemia is a predictor of delayed postoperative bowel function and poor surgical outcomes in right-sided colon cancer patients

PURPOSE: To determine the relationship between preoperative serum albumin and postoperative bowel function as well as surgical outcomes in right-sided colon cancer patients. METHODS: This retrospective study in a university hospital included 84 patients who underwent elective right hemicolectomy for adenocarcinoma of the right-sided colon between January 2004 and December 2005. The patients had a preoperative serum albumin assessment. Serum albumin less than 3.5 g/dL was regarded as hypoalbuminemia. Postoperative outcomes were classified into mortality, morbidity (infectious and noninfectious complications), time to first bowel movement, time to resume normal diet, and hospital stay. RESULTS: Forty males (48%) and forty-four females (52%) with a mean age of 64 (range, 27-89) years were included. Forty-eight patients (57%) had hypoalbuminemia. No 30-day postoperative mortality occurred. All 14 postoperative complications occurred in hypoalbuminemic cases. Therefore, 29% of the hypoalbuminemics had complications whereas none occurred in nonhypoalbuminemics (p=0.001). In univariate analysis, hypoalbuminemia and postoperative complications were the risk factors for delayed postoperative recovery of bowel function and prolonged length of hospital stay. In multivariate analysis, hypoalbuminemia was the significant risk factor for postoperative complications (p<0.001) and delayed time to first bowel movement (p=0.018) whereas postoperative complications were the significant risk factor for delayed time to resume normal diet (p<0.001) and prolonged hospital stay (p<0.001). CONCLUSION: Hypoalbuminemia is a potential predictor of delayed recovery of bowel function postoperatively and significantly associated with postoperative complications in right-sided colon cancer patients undergone right hemicolectomy.     

Treatment, seizure-free periods, and educational achievements: a follow-up study among children with epilepsy and healthy children.

The medical situation (seizure-free periods, use of medicine, medical supervision) of a group of 136 epileptic children was investigated at the age of 11. One hundred and nine of these children were individually matched with 109 children without chronic illness and their educational achievements were compared. We came by these groups via their family doctors or their schools/teachers respectively. We followed-up their medical and educational situation 5 years later. In this way we have been able to establish long-term trends regarding the medical situation and the educational achievements of the children. From the data it appeared that between half and two-thirds of the children were seizure-free for 5 years or longer. One-quarter, however, seemed to be therapy resident and still had seizures. At the age of 16, four out of 10 children were no longer under the supervision of any health care provider; five out of 10 did not use antiepileptic drugs anymore; but 20% of them still had seizures. There was no evidence of such improvements in the educational careers of these children: their educational levels stayed behind those of the controls.     

Audio-induced psychogenic non-epileptic seizures

A 45-year-old woman presented with vague attacks, which consisted of headaches, confusion and sleepiness. An electroencephalograph was normal, but subsequent scans revealed the presence of a right-sided convexity meningioma. This was excised and complications led to the removal of an infected bone flap in a separate procedure the following year. Various types of 'seizures' resulted from the operation. These were described to involve both tonic-clonic and absence seizures. This continued for 18 years, unaffected by medication, until a specialist diagnosed pseudo-epilepsy, by fortune of a hospital fire alarm. The patient began a psychological intervention programme including cognitive-behavioural therapy, which has significantly reduced episodes. In conclusion, psychogenic non-epileptic seizures may develop after intracranial neurosurgery undertaken for indications other than the control of refractory epileptic seizures. A diagnosis of psychogenic non-epileptic seizures should be considered in patients who develop refractory seizures after neurosurgery and managed appropriately.     

视频脑电图监测对儿童非癫痫性发作的诊断价值

目的 评价视频脑电图(VEEG)在诊断儿童非癫痫性发作(NES)中的作用。方法 对105例经1∽4hVEEG动态监测后诊断为NES患儿的临床资料进行回顾性分析，探讨影响诊断的因素。结果 105例NES中，心理性NES14例(13％)，躯体性NES91例(87％)。43例此前接受过普遍EEG检查的患儿中11例(26％)曾被误诊。结论 VEEG是明确小儿非癫痫性发作的种类、鉴别非癫痫性与癫痫发作的可靠的方法，发作间隙期EEG异常是导致NES误诊的主要因素。