SAME-DAY BRAIN SURGERY

NEW MINIMALLY INVASIVE, FULLY ENDOSCOPIC PROCEDURE MAY RESULT IN SAME-DAY BRAIN SURGERY FOR PITUITARY TUMORS

LOS ANGELES (April 29, 1999) -- A fully endoscopic procedure now available at Cedars-Sinai Medical Center¹s Skull Base Institute is resulting in minimally invasive, highly successful surgery for patients with pituitary tumors and other skull base disorders. According to Hrayr Shahinian, M.D., director of the Skull Base Institute, the new procedure utilizes a tiny endoscope ­ 2.8mm wide and 20cm long -- with angled tips to provide a panoramic view of the brain. Because the point of entry is through a nostril, there is no scarring, the brain is undisturbed and both the time required for the actual surgical procedure, as well as the overall recovery time are dramatically reduced.

Of the more than 50 Skull Base Institute patients who have undergone this type of delicate brain surgery in the past year, virtually all have gone home within 48 hours of surgery ­ the most recent 12 patients have gone home within 24 hours -- and all have enjoyed rapid overall recovery. "I stayed in the hospital for a couple of days, then went roller-blading nine days after I went home," says Ken Baker, 28, a staff correspondent for People magazine. Baker underwent the procedure on July 8, 1998, to remove a large (2.5cm) hormone-secreting prolactinoma.

Brad Sauer, 47, had previously undergone four surgeries to remove his pituitary tumor, and compares his previous surgical experiences (all of which were done using the conventional "open" approach) to the fully endoscopic approach taken by Dr. Shahinian last month. "After the first three operations, I had severe spinal headaches which were not alleviated by medication," he says. In addition, he says the nasal packing used in those procedures was very uncomfortable and he had numerous complications. The fourth operation was better, he says, "but within three months I was having headaches again." An MRI showed that the tumor was back and growing fast.

In contrast, says Sauer, the fully endoscopic approach taken by Dr. Shahinian was much less invasive. "There was no need for a spinal tap, nor for a Lumbar drain," he says. "There was no nasal packing, I had no post-operative headaches this time, and needed very little pain medication. As for the surgery itself, they used a short-acting anesthesia, so I was fully functioning again very quickly ­ which had not been the case with my previous operations." Perhaps most significant of all, was the fact that thanks to the panoramic view provided by the endoscope, Sauer¹s tumor was removed in its entirety.

According to Dr. Shahinian, the new endoscopic technology provides surgeons with an unprecedented panoramic view of the tumor site, allowing them to look around corners and make a full visual assessment. "This enhanced visibility helps us know exactly how to best approach the tumor without disturbing the brain, itself," he says. "In any type of brain surgery, our goal is to disturb it (the brain) as little as possible."

"The second thing the panoramic view provides is the ability to nearly always remove the tumor in its entirety. Prior to the availability of the panoramic view endoscopes, we could not always see or remove the whole tumor, as often a portion of it Œhides¹ around a corner. Now that we can see it fully, we can remove it fully."

Baker¹s tumor was a classic example, says Dr. Shahinian. "In his case, a portion of the tumor extended around a corner into the right cavernous sinus -- a very dangerous area. This represents a venous pool of blood that houses the internal carotid artery, one of the main sources of blood to the brain, as well as nerves that go to the eyes. Without the endoscope, it would have been impossible to see around the corner into this area, and it would have been too risky to try to enter the area blind. The upshot would have been that some of the tumor would have remained, and it would have eventually grown back, requiring additional surgery."

The advantages to the patient are numerous:

• No scarring ("I really like the fact that no one can look at me now and even know I had surgery," says Amelia Anderson, 41, a bank vice president and a patient of Dr. Shahinian¹s.)
• No nasal packing
• Shortened surgery time (At present about 2 hours compared to 4 hours for traditional pituitary surgery. Dr. Shahinian expects that time to shorten even more)
• Dramatically reduced length of stay in the hospital (At present, about 24 hours compared to 5 days for traditional pituitary surgery. Dr. Shahinian anticipates that within the next year or two, this may become a "same-day" surgery.)
• Less discomfort as the brain itself is not disturbed
• Faster overall recovery, return to work and normal activities

“GLITCHES” DISCOVERED AND FIXED IN STUDY MAKE SURGERY FOR HUMAN PITUITARY TUMORS QUICKER, SAFER, AND LESS PAINFUL

Surgeons at the Skull Base Institute at Cedars-Sinai Medical Center have refined an endoscopic procedure that reduces trauma, decreases risk of complications and speeds recovery for patients who need surgery of the pituitary gland.

The animal study that led to the safe use of the technique in human surgery appears in the April issue of the “Journal of Laparoendoscopic and Advanced Surgical Techniques.”

The pituitary gland, about the size of a pea and located beneath the brain and behind the nose, produces a variety of hormones and controls most of the hormones in the body. It is situated in a cup-like area of the skull called the sella turcica, behind and above the sphenoid bone.

To remove tumors of the pituitary, surgeons historically have reached the gland by making a hole in the front of the skull or going through the sphenoid bone at the base of the skull. Although the “transcranial” approach is still sometimes used to remove large tumors, the “transphenoidal” technique is far more common today.

Surgeons typically make an incision under the upper lip or under a nostril, then use surgical tools to clear a path to and through the sphenoid bone and up to the sella turcica. Once there, they use a high-powered surgical microscope to view the tumor and use microsurgical tools to dissect and remove it.

The introduction and evolution of surgical microscopy over the past several decades has given surgeons a close-up, detailed view of their work. But Hrayr Shahinian, M.D., director of the Skull Base Institute, has found that an endoscopic telescope offers a much better look at the entire area.

Switching between two lenses of different angles, the endoscope can be manipulated to provide a view of the spaces around the gland to reveal residual tumor that otherwise might not be detected. The telescopes also give better definition of the relationships between the pituitary and surrounding structures. Furthermore, because the telescope’s tube is smaller in diameter than a microscope’s, surgeons may leave more tissue and bone intact. In fact, instead of cutting through the tissues of the mouth and nose, Dr. Shahinian and his team approach the sphenoid bone directly through a nostril and the nasal passages.

“We put a 2.7 millimeter telescope into the nostril and take the tumor out through the nose,” he said. “There are no incisions, no scars, and the duration of surgery is shortened because we don’t have to do the full approach anymore. There are fewer complications and patients go home the next morning. I have no doubt that within the next five years, this will be the method of choice.”

In comparison, because of the larger incisions, greater trauma and increased risk of intranasal complications, patients who have undergone microscopic surgery generally have their noses packed with gauze for several days and remain in the hospital for about five days.

“About three years ago, I was doing all of these surgeries with the microscope,” said Dr. Shahinian. “Then I started taking an endoscope and, after doing the procedure with a microscope, I’d insert the endoscope to look around corners. Then I thought, ‘Why am I doing all the approach, all the big dissection with the microscope and then putting the endoscope in?  Why can’t I just do it with an endoscope, period?’”

To be sure the new procedure would be safe, Dr. Shahinian’s team, assisted by veterinarians, attempted to remove the pituitary glands of two pigs using the telescopes alone. Pigs were chosen as subjects because their skulls are anatomically similar to those of humans.

“Our experiment was conceived to demonstrate two principles,” said Dr.  Shahinian. “First, we wanted to show that we could gain access to and adequately expose the sphenoid sinus completely transnasally. In other words, we wanted to show that we could reach the space housing the pituitary gland through the nasal passages, without the need for incisions in the mouth or nose. Second, we hoped to document our claim that the areas around the pituitary could be better visualized with the telescope than with the microscope.”

The researchers encountered several unexpected problems. First, because of the length of the pigs’ snouts, the telescope was not long enough to extend to the back of the nasal cavities. Dr. Shahinian improvised by making an incision in the roof of the mouth. This was considered only a minor setback because endoscopic surgical experience in human nasal passages is commonplace and well-documented.

Once the telescopes were positioned, two additional hurdles were realized.  The doctors found that holding the operating equipment in one hand and manipulating the telescope with the other tended to be cumbersome at times.  Also, placement of the endoscope’s lens into the surgical site exposed it to fluid and debris, which obscured the view and required frequent removal, cleaning and replacement of the scope.

Both of these problems have since been overcome. A holding arm is now available to lock the telescope in place, freeing both hands for manipulation of surgical instruments, and an irrigation system is used to keep the lens clear.

Performing the procedure on the pigs, which were anesthetized during the surgery and later humanely euthanized by the veterinary staff, allowed Dr.  Shahinian’s team to “fix the glitches” before bringing the technique into the operating room. Since completing the experiment and remedying the problems, which took place about a year ago, he has used the endoscopic technique exclusively.

Before founding the Skull Base Institute in 1996, Dr. Shahinian trained in general surgery, plastic surgery, microsurgery,craniofacial surgery and skull base surgery. This “hybrid” education provides him with a unique set of skills that is perfectly suited to treating pituitary tumors and other disorders that commonly occur at the base of the skull.