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Surgery 2

Surgery 2



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Published by: karendelarosa06 on Jul 26, 2009
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is asurgical operationin which part of theskull, called a
bone flap
, is removed inorder to access the brain. Craniotomies are often a critical operation performed on patientssuffering from brainlesionsor  traumatic brain injury(TBI), and can also allow doctors to surgically implantdeep brain stimulatorsfor the treatment of Parkinson's disease,epilepsyand cerebellar tremor .The procedure is also widely used inneurosciencefor extracellular recording,  brain imaging, and for neurological manipulations such as electrical stimulation and chemicaltitration.Human craniotomy is usually performed under general anesthesia but can be also done with the patient awake using a local anaesthetic; the procedure generally does not involve significantdiscomfort for the patient. In general, a craniotomy will be preceded by anMRIscan which provides a picture of the brain that the surgeon uses to plan the precise location for bone removal and the appropriate angle of access to the relevant brain areas. The amount of skull that needs to be removed depends to a large extent on the type of surgery being performed. Most small holescan heal with no difficulty. When larger parts of the skull must be removed, surgeons will usuallytry to retain the bone flap and replace it immediately after surgery. It is held in place temporarilywith metal plates and rather quickly reintegrates with the intact part of the skull, at which pointthe metal plates are removed.Craniotomy is distinguished from
, in which the skull flap is not replaced, and fromtrepanation, which is performed voluntarily withoutmedical necessity.
Decompressive craniectomy
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Intervention:Decompressive craniectomy 
Decompressive craniectomy
is aneurosurgical  procedure in which part of theskullis removed to allow a swelling brainroom to expand without being squeezed. It is performed on victims of traumatic brain injuryandstroke. Use of the surgery is controversial.
[edit] Results of clinical trials
[edit] Reduction of intracranial pressure
Though the procedure is considered a last resort, some evidence suggests that it does improveoutcomes by loweringintracranial pressure (ICP), the pressure within the skull.
Raisedintracranial pressure is very often debilitating or fatal because it causes compression of the brainand restrictscerebral blood flow.The aim of decompressive craniectomy is to reduce this  pressure. The part of the skull that is removed is called a bone-flap. A study has shown that thelarger the removed bone-flap is, the more ICP is reduced.
[edit] Other effects
In addition to reducing ICP, studies have found decompressive craniectomy to improvecerebral perfusion pressure
 andcerebral blood flowin head injured patients.
Decompressive craniectomy is also used to manage major strokes, associated with "malignant"edema andintracranial hypertension.The pooled evidence from three randomised controlled trials in Europe supports the retrospective observations that early (within 48 hours) application of decompressive craniectomy after "malignant" stroke may result in improved survival andfunctional outcome in patients under the age of 55, compared to conservative managementalone.
The procedure is recommended especially for young patients in whom ICP is not controllable byother methods.
Age of greater than 50 years is associated with a poorer outcome after thesurgery.
[edit] Complications
Infections such asmeningitisor   brain abscess can occur after decompressive craniectomy.
[edit] Children
In severely head injured children, a study has shown that decompressive craniectomy resulted ingood recovery in all children in the study, suggesting the procedure has an advantage over non-surgical treatment in children.
In one of the largest studies on pediatric patients, Jagannathan etal. found a net 65% favorable outcomes rate in pediatric patients for accidental trauma after craniectomy when followed for more than five years. Only three patients were dependent oncaregivers.
This is the only prospective randomised controlled study to date to support the potential benefit of decompressive craniectomy following traumatic brain injury.
[edit] Follow-up treatment
After a craniectomy, the risk of brain injury is increased, particularly after the patient heals and becomes mobile again. Therefore, special measures must be taken to protect the brain, such as ahelmet or a temporary implant in the skull
.When the patient has healed sufficiently, the opening in the skull is usually closed with acranioplasty. If possible, the original skull fragment is preserved after the craniectomy inanticipation of the cranioplasty
[edit] Ongoing Trials
Two prospective randomised controlled trials are currently being run in an attempt to provideClass I evidenceon the role of surgical decompression in the treatment of raised intracranial pressure after severe head injury. The RESCUEicp study[1] is an international multicentre trial, coordinated by the University of Cambridge Academic Neurosurgery Unit[2]and the EuropeanBrain Injury Consortium (EBIC)[3]and the DECRA trial[4] is run and coordinated by the Australian centres[5].
thoracicLung volume reduction surgery for chronic obstructive pulmonarydisease (COPD)
In lung volume reduction surgery (LVRS), a large area of damaged lung is removed to allow the remaininglung tissue to expand when you breathe in. This surgery sometimes is done if you have severe chronicobstructive pulmonary disease (COPD) with severe emphysema.
The National Emphysema Treatment Trial has examined the results of LVRS. The results of this studyreport that people not considered good candidates for this surgery include people who have:
Severely impaired lung function as measured by breathing tests or a uniform pattern of emphysemathroughout the lungs.
Largely non-upper lung emphysema and who are able to exercise for a longer time than other people withCOPD.
Certain other serious medical problems.For other people LVRS, compared to medical treatment, may provide an increased ability to exercise andmay result in fewer symptoms. LVRS also can reduce the number of COPD exacerbations for somepeople.
But it does not improve the survival rate compared to medical treatment, except for people whohave emphysema mainly in the upper portion of the lungs and who are not able to exercise well evenafter pulmonary rehabilitation.
Although selecting candidates for LVRS is subjective, criteria identifying good candidates for LVRSinclude people:
Who have severe emphysema that does not respond to medical therapy.
Who are younger than 75 to 80 years old.
Who have not smoked for at least 4 months.
Who have reasonable expectations of surgery results.
Who have areas of the lung that can be targeted.
Who have severe difficulty breathing, as determined by breathing tests.

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