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With Novel Technique Surgeons Remove 44mm Brain Tumor

(Mar 1, 2009)

Last year, a 50-year-old male patient presented with deteriorating vision and increasing signs of weakness. He eventually collapsed and was taken to the local emergency room. Doctors there discovered a 44-millimeter pituitary tumor in his clivus, sella, and suprasellar cistern that was pressing on his optic nerve. Local neurosurgeons were able to remove part of the tumor, but the patient's condition deteriorated. He contacted neurosurgeons at several major hospitals in a search for one who would be willing to remove the remaining tumor endoscopically. The surgeons told him the tumor could only be removed through a craniotomy. Then, through the internet, he found Theodore H. Schwartz, MD, and Vijay K. Anand, MD.

Skull Base Endoscopic Surgery

Dr. Schwartz, a neurosurgeon, and Dr. Anand, an otolaryngologist work as a team at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, and each year perform 50 to 60 minimally invasive skull base surgeries. "Minimally invasive surgery has been a real revolution in the way we perform pituitary and skull base surgery. Patients tolerate it better and go home sooner. Visualization is actually better with the endoscope even though its opening is smaller than the operating microscope because the endoscope can be angled and look around corners," said Dr. Schwartz.

In addition, "in traditional skull base surgery you have to open up the scalp and the head, move the brain aside, and manipulate the many nerves and arteries that are in the way to remove a tumor that sits at the very base of the skull – all of which can result in complications," said Dr. Schwartz. "Going through the nose is more direct. The endoscope allows us to get a beautiful visualization of the anatomy of the base of the skull and the midline of the brain."

Skull Base Endoscopic Surgery: A Close Collaboration Between Neurosurgery & ENT

Dr. Anand has been performing endoscopic sinus surgery for more than 20 years on patients with inflammatory paranasal sinus disease and cerebrospinal fluid (CSF) leaks. He recalled, "When I met Dr. Schwartz, there was a natural symbiotic thought process, the right chemistry, which is important in two surgical services where the philosophy and principles are a little different."

When operating with Dr. Schwartz, Dr. Anand's primary role is to direct the surgical approach through the sinuses and nasal cavity to expose the tumor, which Dr. Schwartz then removes with Dr. Anand's assistance. The last phase of the operation is reconstruction of the skull base, which is also critical to prevent a CSF leak. The team has developed novel closure techniques, including the "gasket seal," which includes fat and fascia lata from the thigh, a piece of the vomer or high-density porous polyethylene (Porex), and a synthetic sealant such as DuraSeal (Neurosurgery 2008; 62 [suppl 2]: ONSE342-ONSE343). The team has also developed techniques for testing the integrity of the seal with fluorescein dye. Using these innovative CSF sealing techniques, the team has reduced its postoperative CSF leak rate to approximately 6%, far below the national average.

Skull Base Endoscopic Surgery: Improving Care for Patients With Brain Tumors

Drs. Schwartz and Anand, who perform about 50 to 60 cases of endoscopic neurosurgery each year, have recently published a textbook on surgery of the skull base (Anand VJ, Schwartz TH. Practical Endoscopic Skull Base Surgery. San Diego, CA: Plural Publishing; 2007), and teach courses on dissection and surgical technique at Weill Cornell Medical College and nationally.

The team will be directing a two-day, comprehensive endoscopic skull base surgery course combining didactic sessions with hands-on cadaver dissection, on June 5-6, 2009 at Weill Cornell Medical College. Guest faculty will be John Jane, MD, Director of Pediatric Neurosurgery at the University of Virginia Healthcare System.

  • Skull Base Endoscopic Surgery Course Announcement (PDF format)
  • Drs. Schwartz & Anand's Endoscopic Skull Base Surgery web site

Drs. Anand and Schwartz recently returned from the Third World Congress for Endoscopic Surgery of the Brain, Skull Base, and Spine, where they presented results from the NewYork-Presbyterian Hospital experience with minimally invasive endoscopic neurosurgery. Their presentation included conclusions drawn from their database of 225 consecutive endonasal endoscopic operations. With this information Drs. Schwartz and Anand devised a classification of approaches to endoscopic cranial base surgery; this highlights the importance of understanding the 4 nasal corridors for entry and 9 approaches to the cranial base, and identifies 12 amenable intracranial targets (Neurosurgery 2008; 62 [5]: 991-1002). In their experience, the most commonly encountered types of pathology are pituitary tumors (50%), meningocele/encephalocele (14%), craniopharyngioma and Rathke cleft cyst (10%), meningioma (8%), chordoma (5%), esthesioneuroblastoma (2%), and other (11%). The approach can even be used to access the top of the cervical spine and decompress the spinal cord in patients with odontoid fractures and congenital abnormalities of C2 (J Neurosurg Spine 2008; 8[4]:376-380).

A Physiologic Approach to Skull Base Endoscopic Surgery

Drs. Anand and Schwartz take a very "physiologic approach" to endonasal surgery, and reach the operating field without removing parts of the septum and turbinate, leaving patients without the chronic complications that can ensue when these structures are altered during surgery, said Dr. Anand.

Dr. Schwartz described a recent breakthrough in endoscopic surgery. "One of the limitations of endoscopic surgery has been that endoscopes are 2-dimensional, so the image is flat because it's seen by only one eye. We now have the ability to do endoscopic surgery using a special computer chip that's been designed like an insect eye to produce 3-dimensional images, which have to be viewed on a special monitor."

Dr. Schwartz concluded, "Minimally invasive endoscopic surgery is the state of the art. We plan to push the frontiers even farther and maximize what we can do."

Contributing faculty for this article:

Theodore H. Schwartz, MD is an Associate Attending Neurosurgeon at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, and Associate Professor of Neurological Surgery, Surgical Director of the Comprehensive Epilepsy Center, and Co-director of the Institute for Minimally Invasive Skull Base Surgery at Weill Cornell Medical College

Vijay K. Anand, MD is an Attending Otolaryngologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, and Clinical Professor of Otolaryngology and Co-director of the Institute for Minimally Invasive Skull Base Surgery at Weill Cornell Medical College

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