New approach to brain surgery
A revolutionary surgical technique - that uses the nose and nasal sinuses to gain access to the brain and spinal cord - gives UPMC surgeons an exciting new way to help patients with benign or malignant brain tumors.
Endoscopic transnasal brain surgery (ETBS) makes once inoperable problems in some of the body's most critical neurological areas operable. By threading narrow scopes, alongside miniature surgical tools, into the soft tissue of the nasal opening, surgeons now can access tumors from hard- to-reach areas in the brain, and even the spine.
The new procedure, developed and pioneered at UPMC, stands in dramatic contrast to the more traditional surgical technique for accessing brain tumors. Called a craniotomy, it involved peeling away the skin of the face and cutting open the skull, producing considerable facial scarring with high risks of infection, substantial blood loss, and other complications.
"The traditional technique usually meant great disfigurement and a long, painful recovery," says Amin Kassam, MD, co-director of the UPMC Minimally Invasive Neurosurgical Center. "Some patients didn't make it through the very invasive process, or they developed infections afterward."
Now, thanks to the innovative thinking of a uniquely-organized and experienced team of surgeons, the endonasal approach is so successful that patients are often discharged within several days, leaving the hospital with no incisions or scars and few, if any, lingering side effects.
"Instead of taking off large segments of the skull or facial skeleton, we now have a much less invasive way of gaining access to tumors," says Dr. Kassam. "In fact, we can take out baseball-sized growths without pulling on the brain or touching the normal tissue."
UPMC doctors first broached the idea of endoscopic transnasal brain surgery in 1998 and spent the next several years painstakingly researching it. Dr. Kassam and his associate, Carl Snyderman, MD, co-director of the program, had the resolve, the right combination of skills, and the institutional backing to help make their revelation a reality. The physicians not only understood the importance of marrying their fields in the operating room, but also mapped out the anatomy of the undersurface of the brain and skull base to help to ensure a positive outcome.
"We put a head and neck surgeon and a brain surgeon on the same team performing the operation simultaneously. That never happened before," says Dr. Snyderman. "We also developed new surgical tools and a new way of thinking."
It's been almost a century since the first brain tumor was extricated through the nose via a primitive endoscope. The surgery wasn't successful, but since 1909, science has advanced and developed what's now a high-tech answer to many patients' prayers. Better scopes. Better aspirators. Better ways to track tumors. And what UPMC doctors didn't have in their arsenal, they modified or designed, working closely with biomedical companies to produce their instruments. They re-crafted drills and even worked with computerized mapping systems, enabling them to more assuredly navigate the brain through the nasal opening.
By 2000, the doctors had honed their surgical skills enough to start on large pituitary tumors. Working in tandem in the operating room, they slowly amassed a string of successes, building on their track record and skill. Once they mastered grape-sized tumors, the doctors moved methodically forward until they accomplished the same feats with grapefruit-sized growths.
At the same time, further refinement of the procedure allowed Drs. Kassam and Snyderman to successfully target ever-widening zones in the brain, from the leather-like "dura," or lining of the brain, to the central core. They also proved they could control bleeding, no matter how buried or contorted the growth.
"There are very few instantaneous discoveries in medicine," says Dr. Snyderman. "Everything, including surgery, is incremental - built on the foundation established by other physicians. That's what happened here. We took many baby steps."
With 350 cases to their credit, the team can point to success after success:
- A pregnant woman near blindness regains her sight when doctors remove a brain tumor completely through her nose, without putting her baby at risk.
- A 2-year-old with torrential nosebleeds gets a lifesaving reprieve when doctors remove the abnormal vessels causing havoc with her sinuses and skull base.
- A patient with strict religious beliefs surrounding surgery leaves UPMC satisfied after doctors are able to excise nose, sinus, and skull-base tumors without a blood transfusion.
For many patients, ETBS is an answer to their prayers. Patients with deep-seated brain tumors, who were once told there was no surgical treatment to help them, now have an excellent chance of successful treatment and a full recovery.
Similarly, patients with malignant cancers now benefit greatly from the endonasal approach, because they can start chemotherapy or radiation therapy almost immediately, giving the drugs a chance to work before the tumor returns.
"One of the drawbacks of conventional outside-in surgery for cancerous brain tumors is that by the time the wounds heal enough for follow-up treatment, the doctor's surgical handiwork may be undone by tumor regrowth," says Dr. Snyderman.
Still, endoscopic transnasal surgery isn't without risks. Cerebral fluid leakage is a potential complication. Also, because of the smaller access point, doctors may have to perform additional endoscopic surgeries to remove some larger tumors in sections or stages.
Yet, the benefits, say proponents, far outweigh the risks. Today endoscopic transnasal brain surgery is the UPMC standard-of-care for many pituitary and sinus tumors. It's also become a treatment-of-choice for difficult cases, or for patients with complications.
The hope is that this minimally invasive transnasal approach will yield exciting results for a variety of other applications in neurosurgery. In the meantime, physicians at UPMC are busy teaching other doctors what they've learned.
"Our primary goal is to preserve neurological function," says Dr. Kassam. "We do everything we can to make sure that a patient walks out well. It's really exciting to feel that we have the opportunity to make a difference, and that we're educating a whole new generation of surgeons to develop this approach even further."