Dr. Oleksandr Voznyak, M.D., Ph.D.: “Neurosurgery is handiwork”

Олександр Возняк: «Нейрохірургія – це рукоділля»

Innovation House keeps on making you acquaint with the best Ukrainian neurosurgeons and neurosurgical clinics.

Renovated second bulk of Feofaniya Hospital looks much like the hospitals from House, M.D. or Grey’s Anatomy TV series. Modern building, the ultimate in purity, high-speed elevators, pointers are everywhere. You may use these pointers to orientate yourself in long corridors. This is where Neurosurgery Center has settled down on the 5th floor.

Renovated second bulk of Feofaniya Hospital

To this Center patients are sent with the most complicated cases from all over Ukraine and from abroad. Key specializations of Clinic are neuro-oncology, spine and spinal cord surgery, neurotrauma, vascular neurosurgery, functional and reconstructive surgery. This is where degenerative-dystrophic spine disorders are being treated.

Key specializations of Clinic are neuro-oncology, spine and spinal cord surgery, neurotrauma, vascular neurosurgery, functional and reconstructive surgery

This is also a place, where people suffering from epilepsy, trigeminal neuralgia, torsion dystonia, disturbances of CSF circulation in brain are treated – briefly speaking, possibilities of Center cover almost all range of cerebro-spinal axis diseases. On the average, every year Center conducts about 500 operations, 350 of which relate to tumors of cerebro-spinal axis (7% of the total number of oncological neurosurgical operations in Ukraine).

Dr. Oleksandr Voznyak, M.D., Ph.D.

In most cases is the person needs complex and qualified help, inaccessible in the hinterlands, he is directed not to the Feofaniya neurosurgery, but personally to the Head of the Center – Dr. Oleksandr Voznyak, M.D., Ph.D.

Innovation House had a talk with Dr. Oleksandr Voznyak M.D., Ph.D. about the level and possibilities of Ukrainian neurosurgery, about the problems that shall be overcome by domestic experts, as well as about innovative technologies and training of neurosurgeons.

Dr. Oleksandr Voznyak

Head of the Center of General Neurosurgery and Neurovascular Pathology at Feofaniya Clinical Hospital, Vice President of the Ukrainian Association of Neurosurgeons, M.D., Ph.D., Associate Professor of Department of Neurosurgery of National Medical Academy of Postgraduate Education

Dr. Oleksandr Voznyak, M.D., Ph.D. is practicing for 25 consecutive years and is specialized in skull base surgery, neuro-oncology, transsphenoidal neurosurgery. Over the years of practice he conducted more than 5 thous. operations, more than 1 thous. of which – through the nose. Having worked 18 years in Romodanov Neurosurgery Institute in the year 2009 he established and took the lead of Neurosurgery Clinic at Feofaniya Hospital. From year to year a growing number of patients from abroad turn there. According to Dr. Oleksandr Voznyak, M.D., Ph.D., treatment results of his Division is no worse than in Western clinics, and, perhaps, even better.

Dr. Oleksandr Voznyak, M.D., Ph.D.: “Neurosurgery is handiwork”

Indicators of postoperative mortality and complications in Center of Neurosurgery at Feofaniya are several-fold lower than nationwide ones. During 6 months of 2017 postoperative mortality indicator in Clinic was 0.8%, postoperative complications – 0%.

Indicators of postoperative mortality and complications in Center of Neurosurgery at Feofaniya are several-fold lower than nationwide ones

About problems

The biggest problem is the total distrust of patients to our surgeons. Secondly, distrust to the clinics themselves. People do not believe that clinics can ensure minimal patient safety. Starting from the stair, on which you may easily catch your foot, end ending with the quality of bandaging material sterilization. I cannot say that this is groundlessly. Intrahospital management organization is the global problem of the whole country. All the tertiary health care is currently held in place by the enthusiasm of ordinary doctors and heads of departments.

About possibilities of Ukrainian neurosurgery

You may hardly find any pathology that is not treated in Ukraine. We have rather high healthcare delivery level.

Let’s take a closer look at glioblastoma. Glioblastoma is one of the most malignant and aggressive tumours. Unfortunately, the number of patients having such tumors is growing. When I started about 25-30 years ago, up to half of the patients were diagnosed with “nonmalignant astrocytoma”, and nowadays this number is about one-fifth only. Majority of patients suffering from astrocytomas, who come to us, have malignant changes.

Glioblastoma is one of the most malignant and aggressive tumours

There is one more tendency – increase in the aggressiveness of gliomas. As a general rule, most of the gliomas require no super-complicated surgery. They are perfectly operated at the level of regional hospitals. Our country has everything, which is needed for further treatment. There is a so-called international treatment protocol – wherever the patient goes with the same glioblastoma, he will be treated pursuant to this protocol. Surgery is the first stage. If it is impossible to remove tumor – biopsy followed by radiation and chemotherapy will be performed pursuant to pathohistological report. The first line of chemotherapy is also standard for almost all glioblastomas. Ukraine has more than enough irradiation apparatus. Irradiation is performed by the same spectrum throughout the world – the only difference is that this is much more expensive abroad.

When I started about 25-30 years ago, up to half of the patients were diagnosed with “nonmalignant astrocytoma”, and nowadays this number is about one-fifth only.

About training of Ukrainian neurosurgeons

You may easily find good neurosurgical departments that render high-level medical care in each Ukrainian region. There are weak regions, there are stronger ones as well. Ukraine has centers, where neurosurgery is well-equipped and has skilled experts. First and foremost this is Kyiv city. Romodanov Neurosurgery Institute is the core institution, where highly skilled experts work. No matter what people say, no matter what rumours are about, there is school there. Most of the Ukrainian neurosurgeons got basic education there. When it comes to the competence and staff training – this is Emergency Care Hospital and Neurosurgery Institute once again. Here, in Feofaniya we do our best to be the center of excellence.

Dr. Oleksandr Voznyak, M.D., Ph.D.: “Neurosurgery is handiwork”

The second Ukrainian center in order of importance and neurosurgery level after Kyiv is located in Uzhhorod city. Uzhhorod Regional Centre of Neurosurgery and Neurology, established by Volodymyr Ivanovych Smolanka. This Centre is perfectly equipped. They have developed the directions that were developed in our institution before – epilepsy surgery, for instance. Next city is Dnipro, of course. There are some powerful departments there. Odesa city has rather good neurosurgery. Over the past few years Lviv city worked its way forward.

About advanced techniques and equipment

If truth be told, fundamentals of neurosurgery were formed by Harvey Williams Cushing as early as in 1930s. There is no doubt that from that moment on they are constantly improving. Most notably – equipment. Microscopes, endoscopes, intraoperative imaging, intraoperative monitoring, in other words safety and security arrangements for the patient during the operation. We are constantly learning. We go abroad to attend top-tier trainings in surgical dissection, where the most complicated operations on autopsied specimen are conducted under the supervision of seasoned workfellows.

About skull base surgery

It just so happened, that I became the leader of skull base surgery in Ukraine. Primarily, thanks to the fact that I have studied this surgery and started to conduct it. As of today I’m world-famous. My reports take up prime time positions of world’s congresses, foreign universities invite me to give lectures.

Skull base surgery is very high-tech. I have almost everything in Feofaniya to deal with it. Good microscope OPMI Pentero 900 of Carl Zeiss Meditec AG company. This was a flagship model up to 2017, the gold standard. Well, the German Zeiss, like the German car, is reliable and easy-to-use. Neuronavigation to understand where you are at every single moment of operation. Moreover, I have smaller devices too – intraoperative drill, ultrasonic aspirator, portable doppler machine, etc. Such micro-tools as scissors, dissectors, cutters that enable you to work with 20- to 24-fold magnification are of great importance. These things are quite expensive – most of them were purchased by me and my workfellows in Japan, the USA, Europe.

Dr. Oleksandr Voznyak, M.D., Ph.D.: “Neurosurgery is handiwork”

Bipolar forceps and aspirator that dries up the surgical area are actually the key tools of the neurosurgeon. And all the rest – is only neurosurgeon’s skills. All my aspirators are made in Japan and are of ultra-high quality. These are the little things, from which treatment success of the patient is originating. I will say one more time – knowledge, knowledge and once again knowledge. This is the only important thing.

Specialization of the Clinic

Currently we operate any and all tumors of cerebro-spinal axis. This is what we are good at. It so happens that patients “flock” to us with, I suppose, the most complex neoplasms of the nervous system. My workfellows from all over Ukraine send some of their patients to me personally, because they are sure of my competence. It’s like this, you see, I have chosen this field of activity, where skills and knowledge are the key players. Skull base meningioma, for instance, – is the huge tumor, very vascularized (when blood vessels are overgrown with tumor – Editor’s note) and bleeding. If it is conducted by low-skilled surgeon, everything will end with the death of the patient on the table caused by blood loss.

Currently we operate any and all tumors of cerebro-spinal axis. This is what we are good at.

About neurosurgical operation stages

Any brain operation consists of certain stages. When the skin is cut, cranial trepanation is conducted – bone is lifted up, cavity of skull is opened to reach the tumor. Next stage – approach to the tumor and its removal, then we shall close the cover, put bone on its place and close the wound. Almost all the brain operations are performed using this scenario.

Cerebrospinal fluid shunting and draining operations are the exceptions. Small trepanation is needed there. Either endoscope or pathfinder are inserted – these are minimally invasive already.

When it comes to neoplasms located on the skull base in the area of sella turcica, under the brain, surgical approach through the nose is applied. These operations through the nose require less time, they are minimally invasive, less traumatizing. You can use both microscope and endoscope here. Nowadays endoscope is used in increasing frequency. There are combinations of endoscope and microscope – in this case, much depends on clinic possibilities and and neurosurgeon preferences.

About training

I have visited various courses and internships abroad a great many times. There were so-called hands on there – when we gained surgical proficiency using the autopsied specimen. At present, my workfellows visit such trainings at regular intervals. We want to hold similar trainings in our country, but we cannot do this. Ukraine has no legislation regulating the possibility of autopsied specimen obtaining for the educational purposes. Previous law on transplantation is suspended, new one was passed in a first reading as far back as in 2016, after this it died away. Therefore we are forced to go abroad. The starting cost of this training course is €1 thous. in Europe, in the USA – from $2 to 3. Otherwise you will not learn anywhere.

I do not know anyone who would start high-tech neurosurgery with us from the scratch. It’s impossible. Therefore, each of my workfellows performing neurosurgery of high quality, studied in the USA, Japan, Europe.

I do not know anyone who would start high-tech neurosurgery with us from the scratch. It’s impossible.

We learn all our life. I’m 52 now, and I’m not ashamed of going to some trainings and to study – it’s fine, therefore half of them are like me. I arrive with clear goal – I need this very field and this very stage of such an operation. I could not afford to practice this during the operation, since it’s too much of a risk. Great many neurosurgeons do so – in order to make progress, dig in anatomy, to be ready to work with the patient.

We learn all our life. I’m 52 now, and I’m not ashamed of going to some trainings and to study – it’s fine, therefore half of them are like me.

About his workfellow and teacher, Dr. Takanori Fukushima, MD, neurosurgeon

My teacher, friend and mentor – Dr. Takanori Fukushima, MD, one of world’s best neurosurgeons. We made friends in 2007. By that time I have already been well-established neurosurgeon, but meeting with him changed my attitude to neurosurgery. I started to talk to him a lot, I visited him. There were six trips to Japan, I watched 5 to 7 operations conducted by this expert a day. Then, I attended his trainings is the USA. He visited me twice in Ukraine. Moreover, he presented us with many tools.

About neurosurgical technique

The first thing I learned from Dr. Takanori Fukushima, MD is surgical technique. Equipment is of great importance, but surgery is handiwork. Technique is the attitude to tissues, bleeding control method, approaches formation. This all starts from patient positioning on the operating table. If you laid him wrongly and fixed the head improperly, there will definitely be mistakes.

It is my belief that it is impossible to perform proper neurosurgery without head fixation. Patient is anesthetized, he can not protect himself. Even if skin crease is formed somewhere in his body, and body is not ventilated in it, pressure ulcer will emerge there in 4 to 5 hours, and we will have to treat it.

Dr. Oleksandr Voznyak, M.D., Ph.D.: “Neurosurgery is handiwork”

With the lapse of time, when the experience is gained, I start performing operations with fewer tools with increasing frequency. Sure thing, high-tech equipment and tools are needed: first and foremost to mitigate the risks associated with the complications for the patient and to decrease psychological and physical strain on the surgeon. But all the high-priced tools are just the supplement to the experience and skill of the surgeon, without which all of them are just bunch of metal.



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