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Brainstem arteriovenous malformations (AVMs) represent 2% to 7% of all brain AVMs. [1][2][3] Compared with other locations, a greater proportion present with hemorrhage and subsequently have a worse prognosis. 2,4 Surgery has been associated with poor outcomes, 5,6 with parenchymal AVMs associated with higher rates of incomplete resection and morbidity compared with subpial type. 7 Concerns over latency from radiosurgery to obliteration after hemorrhage, potential for incomplete obliteration, and risk of adverse radiation effects are cited by proponents of surgery. [6][7][8][9] Limited access to the anterior brainstem and difficulty controlling deep feeders add to the complexity of surgery. Previous authors have recommended occlusion in situ for parenchymal brainstem AVMs. 9,10 We present a case showing microsurgical management of a parenchymal midbrain AVM. The patient, 46-year-old man, presented with an acute headache and diplopia following hemorrhage 1 year prior. Examination revealed bilateral ptosis, conjugate upgaze palsy, right abduction paresis, and normal light and accommodation reflexes in keeping with a dorsal midbrain lesion. Magnetic resonance and digital subtraction angiography confirmed a compact midbrain AVM (1.6 cm) extending from the pulvinar thalamus to the right quadrigeminal plate, supplied by posterior thalamoperforating, right posteromedial choroidal and branches of the P3 segment and SCA posteriorly, and drainage by the vein of Galen. Tractography showed displacement of the long tracts. A combination of a posteroanterior microsurgical approach and selective anteroposterior embolization of feeders allowed complete resection with no new deficits. The patient consented to the procedure. We demonstrated that brainstem AVMs can safely be resected in experienced hands, with selective preoperative embolization, use of indocyanine videoangiography, and intraoperative neurophysiological monitoring. The patient signed the Institutional Consent Form, which states that he accepts the procedure and allows the use his images and videos for any type of medical publications in conferences and/or scientific articles.

Introduction Placement of a duodenal or pyloric stent is a recognised palliative procedure for symptomatic relief of malignant gastric outlet obstruction. This procedure can be associated with significant complications, reinterventions and poor long-term relief of obstructive symptoms. However, there may be a faster return to diet and shorter hospital stay in comparison to other palliative procedures (eg gastrojejunostomy). The aim of this study was to determine the safety and efficacy of duodenal stenting in our regional district general hospital in comparison to that of larger tertiary centres. Materials and methods All patients with gastric outlet obstruction who had duodenal stent placement attempted in our region between 1 August 2013 and 31 July 2018 were identified by retrospective analysis of prospectively maintained coding databases and medical notes. Patient demographics, safety outcomes and efficacy outcomes were then extracted. Results were interpreted with respect to data from best available published evidence from larger tertiary centres. Results Of 43 duodenal stent insertion attempts, 84% had a successful return to diet, 18% underwent reintervention, 18% suffered adverse events, mean length of stay post-intervention was 8.6 days and mean survival post-intervention was 132 days. Conclusions Patients with malignant gastric outlet obstruction in whom duodenal stent placement was attempted had similar outcomes to published data from larger tertiary centres. Duodenal stent placement remains an acceptable treatment option for these patients in our region.

An 85-year-old man with no previous laparotomies and no herniae presented with a small bowel obstruction. CT imaging did not suggest any obvious cause; however, a transition point at the terminal ileum was noted. At laparotomy, the small bowel was unexpectedly found to be obstructed through a tight anterior hiatal defect. No resection was required and the defect was closed. On retrospective review of the CT images, the herniated small bowel can clearly be seen anterior to the oesophagus and can also be appreciated as a retrocardiac air–fluid level on chest X-ray (initially felt to be a small type I hiatal hernia). Our case highlights the surgical axiom that in patients with small bowel obstruction with no scars and no herniae consideration should be given to an unusual or sinister cause.