癫痫外科的进展

癫痫是一种非常常见的疾病,单纯用药物常难以控制其发作,而通过外科手术则可以完全消除。然而由于传统观念的影响,目前只有少数患者接受手术治疗。     

Certificates of added qualifications in orthopedic surgery

The debate on the issue of certificates of added qualifications (CAQs) will continue since the arguments are strong in each direction. Unlike orthopedic surgery, the vast majority of medical specialties link certification with accreditation (CAQs with fellowship training). Differentiation in specialties and subspecialties is inevitable because of the advances in science and technology and the influence of social and economic factors. Accreditation and certification both have an important role in the definition of new and established subspecialties and the goal to genuinely improve patient care. Constant and repetitive reassessment of these issues is critical.     

Image-guided epilepsy surgery

Interactive image-guided techniques used in conjunction with three-dimensional images allow accurate planning and performance of a variety of neurosurgical procedures. The frameless stereotactic Viewing Wand System was used to provide real-time correlation of the operating field and computerized images in over 22 neurosurgical operations carried out for intractable epilepsy. The overall results of the surgery demonstrated favorable results, with class 1 + class 2 outcomes in 86.4% of the present series. Our experience shows that the Viewing Wand System is most helpful as an adjunctive navigational device in the microsurgical treatment of epilepsy.     

Measuring competence in endoscopic sinus surgery.

BACKGROUND: Competence based education is currently being introduced into higher surgical training in the UK. Valid and reliable performance assessment tools are essential to ensure competencies are achieved. No such tools have yet been reported in the UK literature. OBJECTIVE: We sought to develop and pilot test an Endoscopic Sinus Surgery Competence Assessment Tool (ESSCAT). The ESSCAT was designed for in-theatre assessment of higher surgical trainees in the UK. METHODS: The ESSCAT rating matrix was developed through task analysis of ESS procedures. All otolaryngology consultants and specialist registrars in Scotland were given the opportunity to contribute to its refinement. Two cycles of in-theatre testing were used to ensure utility and gather quantitative data on validity and reliability. Videos of trainees performing surgery were used in establishing inter-rater reliability. RESULTS: National consultation, the consensus derived minimum standard of performance, Cronbach's alpha = 0.89 and demonstration of trainee learning (p = 0.027) during the in vivo application of the ESSCAT suggest a high level of validity. Inter-rater reliability was moderate for competence decisions (Cohen's Kappa = 0.5) and good for total scores (Intra-Class Correlation Co-efficient = 0.63). Intra-rater reliability was good for both competence decisions (Kappa = 0.67) and total scores (Kendall's Tau-b = 0.73). CONCLUSION: The ESSCAT generates a valid and reliable assessment of trainees' in-theatre performance of endoscopic sinus surgery. In conjunction with ongoing evaluation of the instrument we recommend the use of the ESSCAT in higher specialist training in otolaryngology in the UK.     

The surgery of epilepsy

The idea of surgical treatment for epilepsy is not new. However, widespread use and general acceptance of this treatment has only been achieved during the past three decades. A crucial step in this direction was the development of video electroencephalographic monitoring. Improvements in imaging resulted in an increased ability for preoperative identification of intracerebral and potentially epileptogenic lesions. High resolution magnetic resonance imaging plays a major role in structural and functional imaging; other functional imaging techniques (e.g., positron emission tomography and single-photon emission computed tomography) provide complementary data and, together with corresponding electroencephalographic findings, result in a hypothesis of the epileptogenic lesion, epileptogenic zone, and the functional deficit zone. The development of microneurosurgical techniques was a prerequisite for the general acceptance of elective intracranial surgery. New less invasive and safer resection techniques have been developed, and new palliative and augmentative techniques have been introduced. Today, epilepsy surgery is more effective and conveys a better seizure control rate. It has become safer and less invasive, with lower morbidity and mortality rates. This article summarizes the various developments of the past three decades and describes the present tools for presurgical evaluation and surgical strategy, as well as ideas and future perspectives for epilepsy surgery.     

Anesthesia for epilepsy surgery

Epilepsy is rather common, affecting 0.5 to 2% of the population. Numerous patients, particularly those resistant to the antiepileptic therapy, can be surgically treated after a thorough evaluation. Surgery for epilepsy can be carried out either under general or local anaesthesia with sedation. This second approach is reserved for the extirpation of foci localised in motor, sensory or language areas. During the preoperative anaesthetic evaluation, two specific points have to be taken into account: the psychological aspect and the antiepileptic medication. During the procedure, an electrocorticography with or without stimulation may be indicated, particularly when a perioperative stimulation is scheduled. Low doses of volatile agents are chosen, and no curare and large doses of benzodiazepines and barbiturates. Awakening takes place on the operation table for a rapid and reliable neurological evaluation. During procedures performed under local anaesthesia, the anaesthetist must be ready at any time to intubate the patient in order to secure the airway.     

儿童癫痫的外科治疗探讨

目的 探讨儿童顽固性癫痫的外科治疗措施.方法 回顾性分析2004年4月至2006年4月期间的96例患儿的临床资料和外科治疗方案.结果 经神经内外科、儿科等多科室评估,78例采用切除性手术、17例采用姑息性手术、1例采用立体定向毁损手术.手术疗效以Engel标准评判.在14～26个月的随访期间,Engel Ⅰ级者58例、Ⅱ级者26例、Ⅲ、Ⅳ级者12例,总有效率87.5%(Engel Ⅰ级、Ⅱ级患者所占比例);81例患儿的神经心理功能有不同程度改善;22例患儿出现术后并发症,在随访期间15例完全恢复,1例死亡.结论 儿童顽固性癫痫多为症状性癫痫和特殊癫痫综合征,手术可有效控制或缓解癫痫发作并能部分改善患儿神经心理功能.     

Basic science and epilepsy: experimental epilepsy surgery

Epilepsy surgery, as is employed for the management of intractable seizures, was performed in animals harboring a seizure focus induced by a local application of kainic acid (KA). Amygdalo-hippocampectomy failed to stop spontaneous seizures in the contralateral hippocampus. Callosotomy inhibited seizure propagation to the contralateral sensori-motor cortex. However, epileptic activity ipsilateral to the focus, including subcortical structures, persisted even after the callosotomy. Multiple subpial transection (MST) around the epileptic cortical focus suppressed the seizure activity of the cortex. However, seizure propagations in subcortical structures remained, even after MST. Nefiracetam (a new nootropic agent) was tested in these models, and its promising effect on the intractable extratemporal epilepsy is reported.     

Electrophysiological investigations in childhood epilepsy surgery

Epilepsy surgery in children is a functional surgery: its goal is to perform the resection of the epileptic brain tissue while sparing the eloquent cortex. Prolonged scalp video-EEGs allow recording of all types of seizures and play a crucial role in localizing the epileptogenic zone. Furthermore, EEG data correlation with clinical and radiological findings provides a guide for the surgical strategy: either resection without further investigations or an invasive recording procedure. In prehemispherotomy evaluation, EEG recordings confirm that limited resections are not indicated and demonstrate that the opposite hemisphere is not involved. If invasive recordings are needed, they consist in foramen ovale electrode insertion, which provides valuable information in mesial temporal lobe epilepsy, stereoelectroencephalography for children older than two years, and subdural grids associated with depth electrodes in infants or when the eloquent areas need to be carefully investigated. Such investigations allow tailoring surgery to each child.     

Training in pediatric surgery

Pediatric surgery is a small, popular specialty with a limited number of formal, structured training programs. Basic training should place emphasis on the general principles of surgery. Picking a trainer and working in a program that gives a genuine mix of training and experience with adequate supervision are the next steps. The importance of research, the discipline of writing, and the character-building experience of ensuring publication are emphasized. Examinations are a necessary part of development. Depending on career objectives, a varied experience in a number of institutions is a valuable long-term investment.

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Resumen El Dr. B. O'Donnell describe su vision personal sobre el adiestramiento en cirugía pediátrica, una de las especialidades médicas mas pequeñas con programas propios de capacitación de postgrado. Actualmente hay menos de 500 cirujanos pediátricos de tiempo completo en la Asociación Americana de Cirugía Pediátrica, al tiempo que en los Estados Unidos hay mas de siete mil urólogos. En Gran Bretaña hay unos setenta cirujanos pediátricos para una población de 55 millones.El lema de la Asociación Médica Británica, Con Cabeza y Corazón y Mano, podría ser uno muy apropiado para los cirujanos pediátricos. El adiestramiento del cirujano pediátrico debe incluír un conocimiento profundo en las ciencias básicas; experiencia suficiente en cirugía general, incluyendo urgencias y trauma, para adquirir los principios generales de la cirugía, bajo educadores capaces de promover la capacidad de juicio y el desarrollo de una mente inquisitiva en el educando, dentro de un debido equilibrio entre labores de servicio y de educación; actividades de investigación y estímulo a escribir y publicar; participación en labores que permitan apreciar la complejidad del manejo hospitalario.Todo lo anterior dentro de un programa que intensifique al máximo la experiencia dentro de la propia unidad o servicio, permitiendo que el educando vaya a otras unidades o servicios par adquirir la necesaria flexibilidad intelectual que le permita adaptarse a futuras innovaciones, dentro de un amplio círculo de relaciones profesionales.

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Résumé La formation du chirurgien d'enfants relève d'un séjour prolongé dans un service de chirurgie pédiatrique mais aussi de son passage plus bref dans d'autres services de chirurgie. Si le fait d'une formation spécialisée est hautement bénéfique il faut reconnaître que l'acquis dans des services chirurgicaux qui ne se consacrent pas à la chirurgie de l'enfant permet un élargissement des connaissances et des possibilités de création du futur chirurgien pédiatrique.