How early is too early? A review of infant seizure surgery literature

In the US, epilepsy is credited with 2.75 deaths per 1 million people. This number is slightly lower in the UK at 1.79, but higher in Canada at 6.74. (4) Surgery for intractable epilepsy has been in use for hundreds of years, and in recent decades has demonstrated good success. However, many practitioners and the public still view surgery as a last resort, to be explored only after all possible medical therapy combinations have been exhausted and a good length of time has elapsed. Now, however, many major centers have begun to push surgery further and further to the front of their treatment paradigm, predicated on the discovery that medical refractiveness can be predicted after failure of just a few medications. (1) As collective experience grows, the idea that surgery should be planned early in the disease course is gaining momentum. Now that surgical success rates can top 80% in carefully selected cases (2), the American Academy of Neurology, in association with the American Epilepsy Society and American Association of Neurological Surgeons, after reviewing one class 1 and 24 class 4 studies, recommend referral to an epilepsy center so that patients can be expediently evaluated for surgery. (3) Not only is the length of preoperative disease decreasing in these patients, but they are becoming younger. This raises the question: how early is too early? Even if early intervention makes sense in adults, is there a minimum age for which this holds true? Does intervention before this age cause increased harm? Several studies examining this area were reviewed, which in combination demonstrate that seizure surgery in young patients is efficacious. At Dell Children\u27s Medical Center, we advocate early evaluation and surgery for patients with medically refractory epilepsy who are candidates. In the last two years we have done 17 surgeries on patients under 4 years of age, 3 of which have been on patients under one year. Once a patient is deemed medically refractory with a high likelihood of surgical benefit and acceptable surgical risk, we will proceed with surgery regardless of age. Patient selection, however, requires the coordinated effort of a quality multidisciplinary team. © 2012 Bentham Science Publishers

Single-incision laparoscopic transumbilical shunt placement: Technical note

Ventriculoperitoneal (VP) shunt placement is the most common surgical treatment for hydrocephalus. Laparoscopic techniques to aid in the placement of the peritoneal portion have been reported previously. Laparoscopic shunt placement has been associated with decreased operating time, less blood loss, and shorter hospital stays. The authors describe a single-incision laparoscopic shunt (SILS) insertion technique that facilitates directed placement of the peritoneal portion of the catheter in children. A total of 6 pediatric patients underwent the SILS procedure between December 2008 and March 2009. This cohort included 5 girls and 1 boy; the average age was 6 years (range 1 day-16 years). One patient had previously undergone a VP shunt placement, but all other patients were undergoing the initial creation of their shunt. The most common pathological condition encountered was posttraumatic hydrocephalus (2 patients). All patients underwent successful placement of the peritoneal catheters. All catheters were seen to have CSF flowing freely within the peritoneal space. The authors\u27 recent experience shows that SILS placement is safe and feasible in children. It allows accurate, directed placement of the VP shunt with a single, almost invisible, umbilical incision. The shunt tubing is remote from this incision