Prophets that are recognized in their own land. Part I.

Пророки у своїй вітчизні. Частина I.

How Ukrainian neurosurgeons save lives with the aid of their experience, advanced technologies and techniques

What are the possibilities of domestic neurosurgery and why Ukrainians having brain neoplasms and pathologies shall not whip round for treatment abroad.

According to the Ministry of Health, every day 15 people in Ukraine get horrible diagnosis – “brain tumor”. Every year domestic neurosurgeons conduct about 5 thous. surgeries to remove such neoplasms. Experts say that in recent years number of aggressive brain tumors has risen in our country. Unfortunately, but Ukraine is in the world trend in this regard – number of malignant gliomas among all the intracerebral tumors is growing up.

How Ukrainian neurosurgeons save lives with the aid of their experience, advanced technologies and techniques

In addition to neoplasms of different malignant degrees, there are other scary brain pathologies – aneurysms, hydrocephalus, intracranial hematomas. Patients flock in neurosurgeon’s room with all these problems.

Usually, when the first shock of having such a diagnosis is over, the average Ukrainian starts digging for information about his disease. Having tried the internet, he arrives at the conclusion that he shall urgently collect money for treatment and shall go to Israel, Germany or Italy. Anywhere – but not to be operated in Ukraine. Lack of trust in domestic medicine is already something like a national heritage. And when it comes to brain surgery, distrust is admixed with sharp fear.

However, despite well-grounded blames as to the domestic medicine level and a jillion problems that are recognized by experts themselves, capabilities and quality of Ukrainian neurosurgery are currently covering all patients’ needs.

Ukraine has neurosurgeons, who will easily compete with much-hyped Henry March from the UK. Moreover – it is they, who often have to eliminate mistakes of foreign workmates, conducting recurrent surgeries of Ukrainian patients, who tried their fortune in treatment abroad.

Innovation House hereby initiates a series of publications on advanced techniques and equipment that are applied by Ukrainian neurosurgeons, and introduces you to the experts, who, despite their sound experience, keep on studying, developing and polishing up their competence and expertise. They are true innovators, persons, who despite high resistance and great many problems, make Ukrainian neurosurgery in step with Western trends, and even be ahead of them in some cases.
How Ukrainian neurosurgeons save lives with the aid of their experience, advanced technologies and techniques

Andrii Danchyn, MD, PhD, Medical Service Colonel, Associate Professor, Member of the Congress of Neurological Surgeons of the USA, Neurosurgeon of Superior Expert Category, Chief Neurosurgeon of the Ministry of Defense, Head of Neurosurgery Clinic at the Main Military Clinical Hospital

From the senior school Andrii Danchyn spent all his time in operating room of his father – Oleksandr Danchyn, Professor, Doctor of Medical Sciences and Neurosurgeon of Superior Expert Category. Upon graduation from medical institution he joined the military service. Together with his father Andrii Danchyn stood at the origins of minimally invasive neurosurgery in Ukraine.

In 1996, in the clinic at Kyiv city military hospital the first hemorrhage was removed using the endoscope – in other words, through a small hole. Prior to that, such operations required extensive trepanation. Endoscopic technology involves the use of video camera located on a long thin metal tools, endoscope, inside which several working channels are placed. Through them you may insert tiny tools and apply them to manipulate inside the brain. This technology, unlike large trepanation, is more safe for the patient – minimum risk to damage vital deep-seated brain structures and to cause disability to a person.

Upon conducting of several successful operations of such type, in the mid-90s Danchyn family gave a talk on endoscopic removal of hematomas at the IV International Congress in Marburg, Germany. Having impressed by the success of Ukrainian experts, Bernhard Bauer Professor of Neurosurgery invited them to do scientific work in one of the German clinics, where endoscopic techniques were rapidly developed.

As of today Andrii Danchyn is one of the powerful neurosurgeons in Ukraine. His track record includes eight patents for endoscopic operations, doctoral thesis, several monographs, hundreds of successful brain and spinal cord operations. Moreover, he is the head of the clinic at military hospital – leading expert in the country for endoscopic treatment of hydrocephalus, as well as for brain operations using organ-preservation techniques.

Innovation House had a talk with Andrii Danchyn about the level of Ukrainian neurosurgery, advanced treatment techniques applied in his clinic, and about the neurosurgery development boost, given by events in the eastern Ukraine.

About the level of domestic neurosurgery and clinic at the military hospital

It is philosophical issue of how to appraise neurosurgery. But its development level is no worse than in Italy or in Eastern Europe countries. Ukrainian neurosurgery has many good doctors and they are able to conduct good operations. I perform operations on almost all the pathologic processes of central nervous system – in other words, brain and spinal cord as well. Our clinic has multi-field department, therefore here you may find patients with a variety of diseases – both traumas and central nervous system diseases. But as for me, level of care delivery is the same as in Europe.

Our clinic at the military hospital has all the necessary advanced equipment – three-chip endoscopic stand Bristol-Myers Squibb with 3D imaging, modern neurosurgical microscope, C-arch – roentgenologic apparatus that allows you to do the most precise operations on the spine, cold plasma apparatus. Equipment is mostly European or American.

About the patients, who go abroad for the treatment

Since the Soviet Union it is widely thought that somewhere “round there” is better than in Ukraine. But I witnessed the mistakes and failures made by my Western workmates. I had a female patient with malignant meningiomatosis – multiple brain tumors. The first two operations, one in Germany, the second in the Czech Republic, were conducted rather well. But upon what German doctors relied during the third operation – remains unclear. Tumor was in one place, and they made access to it in a completely different place. Operation ended up in failure. It does not work that way is our clinic. Eventually this woman came to us. We looked at medical images and realized that the last operation failed, because the most preferable access to tumor was not chosen. That is why Germans saw no tumor when they conducted trepanation – they could not even reach it.
How Ukrainian neurosurgeons save lives with the aid of their experience, advanced technologies and techniques

About hydrocephalus and causes of its occurrence

Ventricles of the brain have such a structures, similar to fish eggs – choroid plexuses. They produce cerebrospinal fluid. It flows from two lateral ventricles into the third one, from the third one – through the thin tube, water-supply line of the brain, it gets into the fourth ventricle, located where little brain and brainstem are. From the fourth ventricle it drains away to the brain surface and is absorbed there. The total volume of cerebrospinal fluid is about 250 ml. But it is completely renewed 3-4 times a day. In other words, choroid plexuses produce fresh cerebrospinal fluid from blood plasma. If water-supply line is “sealed up” then the obstacle between the third and the fourth ventricles arises. For instance, due to serious acute respiratory disease. And then cerebrospinal fluid is produced, but has no way out. And ventricles start to stretch, become huge, swollen. Person starts suffering from headache, coordination dysfunction, intellectual disorders.

About endoscopic technique advantage in noncommunicating hydrocephalus treatment

Such operations are of physiological nature. Alternative technique – is when the person gets plastic shunt placed. And water from brain ventricles flows through this tube somewhere into the abdominal cavity or jugular vein. Cerebrospinal fluid is constantly produced, but not absorbed, as it should, and is discharged outside the brain. This may cause such complications as hyper-discharge – brain remains completely dry. There may be complications with shunt as well, insofar as this is foreign object. Human body may react negatively to it, struggle with it. And some time later shunt shall be changed. On the other hand, endoscopic technology makes it possible to release patient from hydrocephalus without any tubes. As it happens, today I operated the person, whose shunt fails to operate. I took him to the operating room to remove this useless shunt and to make his life easier. All went well. Endoscopic technology has its restrictions. For instance, field of view is small enough. But it has huge advantages, because video camera lets you work on those deep-seated structures that are unreachable for any microscope or large trepanation, since neurosurgeon will damage enormous number of healthy zones.

About the risks and complications in neurosurgery

Each clinic has complications – human body is unpredictable. There are tumors related to brainstem. In such cases, prior to the operation relatives are always told that neurosurgeons will remove the tumor very gently, but the risk of blood circulation disorders is very high. Small percentage of complications has always been, remains and will be. Famous British neurosurgeon Henry Marsh once showed at one conference how the fatal complication occurs during the operation on endoscopic perforation of the third ventricular floor of the patient having hydrocephalus – if some sharp hook is used, for instance, instead of bar (special electrode – Editor’s note). And Liliequist membrane, in which hole shall be made, is clawed at the underlying artery. The game is over. Your monitor is getting red immediately – you cannot do anything more. You pull out the endoscope and from there aerated blood erupts under great pressure. This is a fatal complication. Thank goodness, fortune favors me – we have never had such complications. But I will bear that in mind for the term of my life. I prefer not to work with sharp tools on such deep-seated structures. I would rather stand 40 minutes on my own feet and will stretch all this mechanically – without electricity, without burning, cutting.

About war, head wounds and tissue-preservation techniques

Situation in the east of Ukraine gave a boost to military neurosurgery as to surgical measures for the wounded. All this was on paper. What is peacetime neurosurgery? This is treatment of complex disorders, central nervous system traumas and here we have vast number of gunshot wounds. Bullet and fragments are characterized by enormous kinetic energy and mechanical disruption. This is very severe brain damages. And neurosurgeon shall immediately make the right decisions, on which life of wounded soldier depends.

Two examples. In spring 2015 I worked in Kharkiv military hospital, where neurosurgical wounded persons were brought. One military man was admitted with penetrating perforating fragmentation wound of skull – fragment hit the left eyebrow, passed through frontal sinuses, having damaged frontal lobes and came out from the right elbow. According to NATO standards, in such cases large skull trepanation shall be made and all the frontal bone shall be removed. You take huge surgical cutter, you bite out the bone having bullet or fragment wound holes, you denude wounded brain tunic and brain, you examine the brain wound. Personally I applied bone-preservation technique, tissue-preservation technique – I sawed out skull section damaged by the fragment, performed surgical debridement of brain wound and by the end of operation, when I saw that the brain retracted, I placed the frontal bone in its place. If brain does not bulge (brain bulging – brain substance protrusion due to brain tunic and cranial bones deficiency – Editor’s note), it means that intracranial pressure returned to normal, and it is preferable to place back the bone. And if you placed back the bone, patient got tremendous advantage – this is physiological tissue, own, native. Such wounded persons shall not be on recurrent operation – no need to conduct plastic repair of cranial bones using the artificial materials. My wounded patient has recovered, no suppurative complications were observed.

And on August 31, 2015, 20-year-old guy was admitted to Kyiv city neurosurgery clinic, where I work – he defended perimeter of the Verkhovna Rada (Ukrainian parliament) building, when someone launched the grenade. In addition to abdominal traumas, he got fragmentation penetrating ballistic wound of the brain. He was already unconscious when he was brought. We made tomography and saw that fragment hit the forehead and teared apart at a number of locations cerebral vein – sinus – as thick as a finger. I immediately took wounded person to the operating room. In this case I also applied tissue-preservation technique. Entrance perforation of skull bone may be used as a hole that is made during the elective operation, but is shall be debrided. I made two additional holes, joined them, sawed out skull bone section as big as about 6 cm by 8 cm. We sewed the vein and saved it. Brain wound was carefully debrided, bleeding was staunched, small bone fragments were removed, hermeticity of brain tunics was recovered, and sawed out bone was finally placed back. When I entered the intensive care unit on the third day, the guy was sitting in the hospital ward and ate by himself.

About neurosurgeon’s school and skill

I passed through German school. And I believe that all neurosurgical operations shall be strictly pedantic. If they are pedantic – there will be no bleedings, if there are no bleedings – there will be good result. There are different situations, when neurosurgeon has no laser and microscope close at his hand. But if it is diagnostically clear where tumor is located, you may conduct operation even with binocular loupe, tweezers, suction with coagulation equally well. All the advanced technologies are for good measure.

Advanced technique for the treatment of hydrocephalus – endoscopic ventriculocisternostomy (endoscopic perforation of the third ventricular floor)

Since 2001 Andrii Danchyn was among the first in Ukraine to apply this effective, with minimal complications technique for the treatment of hydrocephalus. Purpose of the operation – perforation of the third ventricular floor of the brain and Liliequist membrane.

Endoscopic ventriculocisternostomy lets the person get rid once and forever of hydrocephalus, plastic tubes in the head and unpleasant memories of the time spent in the hospital.

Operation is performed in several stages. First small incision of 3-4 cm long is made in the frontal area – on the hairy part of the head. Part of skull bone is removed in the regions of coronal suture and small hole is made. Then, using the high magnification, dura mater of brain is incised. When this is done, endoscope is inserted into the ventricles through the “silent section” of brain cortex. Video camera and bright source of light are placed on the tip of endoscope.

When the neurosurgeon enters the third ventricle using the endoscope and taking cue of the anatomical landmarks, he finds small film between hypophysis and brainstem – Liliequist membrane. Special electrode is inserted through the endoscope – bar that helps surgeon to gently and in a specific way incise and stretch the membrane.

Cerebrospinal fluid is starting to circulate through this stoma (hole), unloading the ventricular cavity.

Author’s technique

During some operations on perforation of the third ventricular floor Andrii Danchyn, in addition to usual and recorded Liliequist membrane, faced one more “obstacle” – the second membrane, deep-seated adhesive process.

“I have not seen analogues until I showed the technique in Rome in 2011, – neurosurgeon said. – And I have never seen before description of this pathology in the literature. But I faced it. Imagine that you opened the door, and yet another door is behind it. But you still want to go into the house. And to do this you shall open the second door. Otherwise you will stay outside. This second membrane is located almost on the brainstem. On the one side you see the stem, on the other – basilar artery and skull bone. This is a small triangle 1 cm by 0.5 cm by 0.5 cm in size. And it is sealed up by the adhesion as solid as the plastic bag. What is to be done? Shall I stop? Shall I finish the operation and put the shunt? I decided that I can try to stretch and incise this second “door” in the same way. It came out as I predicted. And this is – advanced technology, applied in many parts of the world.



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