How sophisticated technologies in transnasal brain surgery are applied in small Clinic of the Institute of Neurosurgery
Huge hospital complex located close to “Lukianivska” Kyiv Metro station looks little like one of the advanced European center. You will not find here shining mirror-like walls, luxurious entrance halls, high-speed elevators, and neighbourly receptionists. However, this is the very place, where year over year more than 35,000 patients having nervous system pathologies of various complexity degrees, undergo treatment.
Romodanov Neurosurgery Institute is the largest specialized institution in Ukraine. It consists of 15 surgical clinics, and scientific and diagnostic departments as well. In spite of not very presentable “appearance”, possibilities of the Institute are no worse than those, of the cutting-edge foreign clinics.
Romodanov Neurosurgery Institute is the largest specialized institution in Ukraine. It consists of 15 surgical clinics
“We remove skull base tumors in endoscopic way for those patients, who were refused at Burdenko Neurosurgery Institute in Moscow city, for instance, or in Germany due to high surgery complexity – at those institutions that, supposedly, are more experienced and more skillful. They do not get down to these cases, because, after all, it is risky. At the same time, we willingly get down to these surgeries, since we are are positive about our own efforts and technologies” – not without vanity said Andrіy Huk MD, PhD, top-category neurosurgeon and deputy director.
“10% of all the patients in Ukraine receive neurosurgical assistance here. 7% of all the neurosurgical interventions in Ukraine are conducted here” – expert added.
According to Eugene Pedachenko, Head of the Institute, establishment is rapidly growing now – most notably in the last decade. Not only equipment was changed here, but the very medical care philosophy as well: “We shall focus on preservation of the quality of human life above. We do this for the patients not to become incapable after the surgery. We want our patients to come back to their works, families, whenever practicable” – Eugene Pedachenko said.
The second advanced principle of the Institute – minimally invasive surgery. Endoscopic transcranial technique, for instance.
“We use laser technologies to treat brain tumors and herniation of intervertebral discs, – explained to Innovation House Vadym Biloshytsky MD, PhD, neurosurgeon of the highest category,, and one of the prominent experts in Ukraine in the field of pain study and treatment. – Neuronavigation for the planning of access to difficult accessing neoplasms in the nervous system. Deep brain stimulation during the treatment of motor disturbances (Parkinson’s disease, torsion dystonia, essential tremor)”. This is only a small part of advanced technologies that are currently used in the Institute.
The second advanced principle of the Institute – minimally invasive surgery. Endoscopic transcranial technique, for instance.
Own researchers are also performed here. For instance, according to Biloshytsky, one of the experiments of local experts substantiated the feasibility of application of gene therapy for major traumatic brain injury treatment. The Institute studies the feasibility of application of new materials for the plasty of skull defects. Application of neuroengineering interventions using the stem cells in case of spinal cord trauma was experimentally validated. Results were published in top Western journals (Scientific Reports for instance).
“Innovation House” starting the series of publications about Institute’s departments.
Pituitary gland adenoma – so dangerous and so unpredictable
Over the recent years one of the clinics of the Institute is being developed very rapidly. It modernizes its surgical techniques and implements the best practices of core foreign profile institutions. We are talking about the Clinic of Transsphenoid Neurosurgery. This is where Ukraine’s first neurosurgical surgery through the nose was conducted.
Since the moment of its establishment in 1988, this Department is headed by Candidate of Medical Sciences Olexandr Huk. Under his command Clinic has become the prestigious all-Ukrainian center for the study and treatment of pituitary gland diseases.
As of today this is the place, where young neurosurgeons work, namely Mykola Guk MD, PhD, Candidates of Medical Sciences Lila Danevych, Arthur Mumlyev, Victor Yatsyk, and Dmytro Tsyurupa. All they are from 31 to 40 years old. Nevertheless, despite youth, they are high-class experts. It is not infrequent for them to struggle with the skepticism and explicit resistance of their aged workmates, who prefer to stay still within their comfort zone – they have no desire to retrain themselves and to master advanced internationally acknowledged neurosurgical techniques.
“We need 5 years to train good endoscopist from skillful neurosurgeon, – Mykola Guk explained. – What is more, this may be done only if the surgeon is able to perceive new knowledge. After all, there are those, who cannot be taught advanced working procedures. More often than not, person, who is on the shady side of 40, will reject the uncomfortable retraining – to look at the screen, rather than at the microscope eyepiece, during the endoscopic surgery, for instance.”
Over the recent years one of the clinics of the Institute is being developed very rapidly. It modernizes its surgical techniques and implements the best practices of core foreign profile institutions. We are talking about the Clinic of Transsphenoid Neurosurgery.
Primary specialization of the Clinic – pituitary gland adenomas treatment. However, they also make surgeries of the tumors of extra-pituitary gland origin, located on the skull base. From a technical point of view, manipulations in this very area of the brain фare the most complex ones in the neurosurgery. Minor mistake may result in severe consequences.
In addition to common pituitary gland adenomas, increasing number of surgeries on brain tumors, that may be reached using the novel endoscopic low-trauma methods (basal meningiomas, craniopharyngiomas, chordomas, etc.), are currently made.
Pituitary gland – tiny gland weighing 0.5 g only. Nevertheless, it is responsible for the most important functions in the body. It is the “bandmaster” of all the human endocrine system. It exercises control over the growth, sexual and reproductive development. Therefore, pituitary gland diseases may not only deprive the patient of full-fledged life, but may put his entire life as such at risk.
Primary specialization of the Clinic – pituitary gland adenomas treatment
Patients having pituitary gland lesion often suffer from outward appearance modifications – for instance, from uneven obesity, when arms and legs remain normal, but abdomen becomes overblown and with stretch marks. Lips, nose, fingers and toes of those, who suffer from acromegalia (when pituitary gland pathology spikes the growth hormones level), are observably grow in size. Pituitary gland adenomas among women cause menstrual disorders, nipple discharge. Pituitary gland adenomas among men lead to low sexual potency and low sex drive. Therefore, sometimes literally desperate men, who demand to cure them, turn to the Clinic. They exasperate neurosurgeons by asking too much, though such patients shall lay a course for sexual health doctor, rather than for surgical table. One of the most dangerous symptoms of pituitary gland tumor is visual deterioration and tunneling of vision. This occurs when the tumor goes beyond the pituitary gland fossa and starts pressing the optic nerves.
Pituitary gland – tiny gland weighing 0.5 g only. Nevertheless, it is responsible for the most important functions in the body
As of today, the Clinic of Transsphenoid Neurosurgery is the place, where those, who suffer from neoplasms affecting the pituitary gland, are rendered assistance. Patients with similar problems from all over Ukraine flock here. An average of no less than 250-300 such surgeries are conducted in the Department. As a rule, regional general neurosurgical centers and departments count such pathologies in dozens or even less.
Since 2011 the employees of the Clinic are actively engaged with mastering and developing of transsphenoidal endoscopic treatment technique – basically, they make surgeries of pituitary gland tumors and skull bases through the nose using the endoscope. Several decades ago such surgeries were conducted not through the nose, but using the large traumatic transcranial access – through the frontal bone. Sad but true, in the early 1970s the postsurgery death rate in the Institute in case of pituitary gland adenomas reached 30%. Over the past few decades, thanks to ongoing developments of minimally invasive transnasal surgery this indicator decreased to less than 1%.
Since 2011 the employees of the Clinic are actively engaged with mastering and developing of transsphenoidal endoscopic treatment technique – basically, they make surgeries of pituitary gland tumors and skull bases through the nose using the endoscope
According to Mykola Guk, there were almost no endoscopic transnasal surgery in the Institute and in Ukraine as a whole before 2011, when the Clinic obtained the advanced equipment.
“We started from the absolute zero level, – said Mykola Guk to Innovation House. – Therefore, I am proud to have such employees. In fact, over the past 3 to 4 years we switched from microsurgical surgery technique through the nose to endoscopy. Nowadays, we master technologies, which are applied in major neurosurgical centers all over the earth.”
How to patch up the brain through the nose
Cost of neurosurgeon’s mistake – death, disability or vegetative state of the patient till his dying day. Therefore, training and learning are the integral parts of the work of any top-ranked expert. From year to year, employees of the Clinic go abroad to adopt the experience of neurosurgeons of world-wide reputation. Arthur, Lila, Mykola, Dmytro, and Viktor studied at leading clinics of Austria, Germany, Italy, France, and the Netherlands.
For instance, while being in Italy, they adopted the multilayer plasty technique for transnasal surgeries, American workmates shared their experience in fractional adenohypophysectomy technique, in other words – partial removal of pituitary gland. According to neurosurgeons, who work at the Clinic, one may sip knowledge in advanced medicine not only from the books on specialized subjects and internships – YouTube videos of surgeries conducted by famous surgeons also help.
The best thing is to explain how these techniques are translated into practice, by the example of surgery, that was recently conducted by Lila Danevych and Mykola Guk.
At the end of October, 53-year-old patient suffering from acromegaly, was admitted to the Clinic. This case is nearly one-of-a-kind – woman has lived with huge pituitary gland tumor for almost 20 years, whereas, on the average, patients diagnosed with “acromegaly” live 20 years less compared to the healthy people.
Two decades ago she refused to get her surgery. However, over the last years microadenoma got bigger and became of gigantic size – its maximum size reached 5 cm. The tumor penetrated into the surrounding structures, ate up the bones and squeezed the optic and oculomotor nerves. Acute visual deterioration, double vision, enlarged lips, fingers, and toes finally made woman to be at peace with the fact that surgery is inevitable.
patients diagnosed with “acromegaly” live 20 years less compared to the healthy people
Lila Danevych said that such surgery begins with adrenalization of mucous membrane of nose. “We lay it over with adrenaline and lidocaine for the mucous membrane of nose to bleed less” – expert explained.
Then, nasal septal flap is formed for its further use to eliminate the defect of removal zone. “Nasal septal flap is the piece of mucous coat in nasal septum, which is separated using the сoagulation. In other words, we burn it away from nasal septum and roll it up towards the inferior nasal meatus, where it will lie, like a fabric piece, waiting for its turn” – neurosurgeon said.
Two decades ago she refused to get her surgery. However, over the last years microadenoma got bigger and became of gigantic size
Then, using the endoscope, doctors removed part of the front wall of basilar bone around the place, where she was already eaten up by the tumor. Surgeons had to “bite out” the affected areas of bones and enlarge the surgical window to reach the tumor.
“This is four-hands work, – Danevych said. – Since that time, when we formed the flap and made hole in nasal septum, two surgeons already worked – the first one with one nostril, the second one – with the other nostril. The first surgeon holds the instrument and works using the aspirator, the second surgeon makes incision, bites out, saws and removes the tumor.”
Dura mater of unique patient was also eaten up with tumor, because neurosurgeons had to remove literally all the damaged tissues – bone, mucous membrane with adenoma fragments, literally “undress” the carotid artery, which was also covered with neoplasm.
“We may do this only through the use of endoscope, – neurosurgeon said. – Since, we were precisely approaching the tumor, shoved the endoscope behind the carotid artery from different angles. This basically allowed us to radically remove the tumor.”
Doctors managed to partially save the pituitary gland. “If its remainders were infiltrated by a tumor, we would have conducted partial adenohypophysectomy. In case of severe forms of acromegaly or relapse of Cushing’s disease, this is justifiable. Most of the clinics do not have a courage to remove fragments of this gland, since they lack of experience to avoid severe endocrine implications” – Lila Danevych explained. According to her, their Clinic is the only clinic in Ukraine, where partial removal of pituitary gland is successfully made.
When the surgeons removed about 85% of the tumor, they proceeded to “patching up” of surgical defects using the Italian technique of multilayer plasty. Experts took small piece of fat and fascia from patient’s leg – small fragment of the muscle case – to prevent the leakage of craniocerebral fluid from the holes, made by the doctors, and to prevent its seeping through the nose, which causes infections or meningitis.
pituitary gland adenoma Clinic is the only clinic in Ukraine, where partial adenohypophysectomy is successfully made
“Fascia is shuffled under the dura mater – such a patch is obtained in such a manner. All this is strengthened with material that stops bleeding. Then on top of it we put big “apron” – that very nasal septal flap from the mucous membrane of nose, which was formed by us at the beginning of the surgery” – Lila Danevych explained the core of the technique.
As a matter of fact, cavities and holes, formed in the brain during the surgery, are kind of “patching up” using the natural tissues of the patient.
Surgery was conducted quite successfully, and vision of the patient, who miraculously lived 20 years with the terrible diagnosis, has improved. Though, unfortunately, double vision will hardly ever fully disappear.
Please print me the skull
The Clinic of Transsphenoid Neurosurgery is the only clinic in Ukraine, where 3D printing of neuro-oncological pathology is used to plan surgical interventions. Arthur Mumlyev MD, PhD, who is 31 years of age, is successfully dealing with the development of this technology.
Surgeries on various skull base tumors are conducted in the Clinic. There are different accesses to this area and surgical techniques.
“We conduct transnasal, endoscopic, and microsurgical surgeries as well. Moreover, we use various transcranial access” – Arthur Mumlyev said.
The choice of surgical access (trepanation option) is not always simple. In complex cases, employees of the Clinic use 3D modeling and 3D-printing to chose the most preferable and less traumatic option for the patient.
The Clinic of Transsphenoid Neurosurgery is the only clinic in Ukraine, where 3D printing of neuro-oncological pathology is used to plan surgical interventions
“While doing their work, neurosurgeons use the standard set of surgical accesses. On frequent occasions, these are large and wide trepanations, which is not always desirable. We use 3D printing to plan minimally invasive surgeries – with minimal trepanation, minimal traumatization of soft tissues and brain, – Mumlyev explained. Minimally invasive trepanation requires proper orientation of the surgeon in the wound, clear understanding of the relationship of the tumor with vessels and nerves. This is actually a challenging task to make this in a narrow surgical window. 3D modeling, 3D printing is one of the methods, that objectifies and simplifies the choice of surgical access.”
According to neurosurgeon, many factors influence on the choice of surgical access. Surgeon shall know and shall definitely consider all these factors at the presurgical stage. These factors include the size, localization, tumor spread rate, anatomical features of skull scaffold. Experts of the Clinic combine the data of computer multislice and magnetic resonance imaging to create the virtual model – nearly identical to the “original”. Afterwards, this model is sent for 3D printing in a special format. All the process lasts about 24 hours.
Then printed model, which has arteries, optic nerves, and tumor, is placed in the laboratory or in the real surgical room. And, for the matter of that, using the real instruments, microscope, and endoscope, simulation of forthcoming surgical intervention is performed.
This “training” helps neurosurgeons to be maximally prepared for the forthcoming surgery, and to conduct is with the lowest possible risk for the patient.