Endoscopic Surgery

[JimGagnepain]

Hello,
I've recently been diagnosed with Accoustic Neuroma.  My tumor appears circular, with a 2.4cm diameter.  I've done some research, and I am very interested in the Endoscopic Surgery.  I live in Colorado, and I am meeting a NeuroSurgeon on Monday, 11-16-2015, in Denver.   However, I don't think the Endoscopic option will be available through this center (or hardly any other center).

I've followed some of the discussions on this site, including those on the ScullBase Institute in Los Angeles.   Can anybody tell me why the Endoscopic method is not mainstream for Accoustic Neuroma treatment?  It seems that it has become mainstream for pituitary and other tumors, through nasal entry.  The Scull Base institute  uses a dime-size entry for accoustic neuromas, and the procedure seems much less invasive.

[CHD63]

Hi JimGagnepain and welcome to this forum .....

Please remember that none of us are medical professionals on this forum, but patients with a large collection of personal experience and research information.

From what I can gather, the biggest risk with using endoscopic surgery for acoustic neuroma removals, is that since ANs grow in the internal auditory canal, which runs from the cochlea to near the brainstem, any adverse bleeding during removal can quickly become a life-threatening event.  If the surgeon has full view of the area, he/she can quickly contain any bleeding, but with a tiny opening it is riskier.

You also need to look carefully at the history of the surgeons doing endoscopic AN surgeries.  Many of the most highly experienced surgeons removing ANs do not look kindly on endoscopic surgery for AN removals because of the increased risks.

Best wishes.  Clarice

[PaulW]

Many surgeons use endoscopic tools to remove acoustic neuromas, this is pretty normal practice. They just don't promote it.
Please research the doctors involved their qualifications and past record.

link worth reading... there are a lot more

http://articles.latimes.com/2010/apr/09/local/la-me-malpractice9-2010apr09

[JimGagnepain]

Many surgeons use endoscopic tools to remove acoustic neuromas, this is pretty normal practice. They just don't promote it.
Please research the doctors involved their qualifications and past record.

link worth reading... there are a lot more

http://articles.latimes.com/2010/apr/09/local/la-me-malpractice9-2010apr09

Yes, thanks for the link, Paul.  I had already read about this.  Based on all of the success stories from Dr. Shahinian, this one blemish on his record, seems very minor.  He admitted to a retraction of the wrong tissue, and paid the fine.  There are many, many stories of life-saving procedures by this doctor, when other facilities were turning patients away.  A search of his name on U-Tube will show many of them.  He also has an extremely good feedback rate on all sites that I visited.

[JimGagnepain]

Hi JimGagnepain and welcome to this forum .....

Please remember that none of us are medical professionals on this forum, but patients with a large collection of personal experience and research information.

From what I can gather, the biggest risk with using endoscopic surgery for acoustic neuroma removals, is that since ANs grow in the internal auditory canal, which runs from the cochlea to near the brainstem, any adverse bleeding during removal can quickly become a life-threatening event.  If the surgeon has full view of the area, he/she can quickly contain any bleeding, but with a tiny opening it is riskier.

You also need to look carefully at the history of the surgeons doing endoscopic AN surgeries.  Many of the most highly experienced surgeons removing ANs do not look kindly on endoscopic surgery for AN removals because of the increased risks.

Best wishes.  Clarice

Thank you Clarice.  I am still leaning towards the Endoscopic, if I can make it work.  I am not sure that my insurance will cover it.  Because it only involves an overnight hospital stay, I thought I would stay in the Los Angeles for a few days, in case there are complications.  I have not heard of any bleeding problems with his procedures, but I would think that, if this did occur, the symptoms would manifest themselves rather quickly.  I'll have to ask this question.  Thanks again.
Jim

[alabamajane]

If you decide this is your choice,, please do report back afterwards and let us know how you do. Will be interesting to hear,,

Jane

[PaulW]

Jim there are a lot more court cases over all sorts of things. Probably sets the scene for the organisation you are dealing with.
I have seen good feedback and not so good.
Minimally invasive procedures are good in many situations especially when cutting through layers of muscle.
Does making an 6cm hole in the skull versus a 2cm hole in the skull actually help anything? Its a bit of extra skin and bone not much else.
Does it really help recovery?

Doctors are already using endoscopic tools now, but choose to have a slightly larger hole, so things like a major bleed can be stopped, or so nerve monitoring tools can be easily placed.

My concerns are that this technique could be considered appealing marketing, with questionable benefit and potentially putting people at higher risk for no benefit.

To the lay person it looks very appealing allowing extra fees to be charged.

Is this just a way to charge extra? or is it real?

There are hundreds of top surgeons removing AN's all over the world, using endoscopic tools to varying degrees.
The skull based institute has been around for quite some time yet nobody is copying this procedure for AN's..
I find that a little strange. If the technique was that good others would be doing it.

[JimGagnepain]

Jim there are a lot more court cases over all sorts of things. Probably sets the scene for the organisation you are dealing with.
I have seen good feedback and not so good.
Minimally invasive procedures are good in many situations especially when cutting through layers of muscle.
Does making an 6cm hole in the skull versus a 2cm hole in the skull actually help anything? Its a bit of extra skin and bone not much else.
Does it really help recovery?

Doctors are already using endoscopic tools now, but choose to have a slightly larger hole, so things like a major bleed can be stopped, or so nerve monitoring tools can be easily placed.

My concerns are that this technique could be considered appealing marketing, with questionable benefit and potentially putting people at higher risk for no benefit.

To the lay person it looks very appealing allowing extra fees to be charged.

Is this just a way to charge extra? or is it real?

There are hundreds of top surgeons removing AN's all over the world, using endoscopic tools to varying degrees.
The skull based institute has been around for quite some time yet nobody is copying this procedure for AN's..
I find that a little strange. If the technique was that good others would be doing it.

Paul,
I've done a lot of searching, and I don't see the "problem" cases that you mention.  I did see examples of incredible tumor removals throughout the brain, using endoscopic methods - even the very center of the brain.  There are examples of surgeries with cuts through the eyebrow, the bridge of the nose, the back of the head, etc - all to get to tumors in different areas of the brain.  I just believe that the ScullBase Institute is more cutting-edge.  Search the name "Shahinian" on YouTube, and you'll see examples of all of these methods.  Here's one on the "Doctors" TV show.

https://www.youtube.com/watch?v=1Fbj2h3NrKM

The question you pose in your last paragraph is the exact question that I posted in my first entry, and one I plan on exploring further.
Thanks for the reply,
Jim

[JimGagnepain]

Paul,
I neglected to mention my main concern about the traditional method.  With that method, the brain is moved out of the way to expose the tumor.  This is not the case with endoscopic, and makes the surgery much less intrusive.
Jim

[PaulW]

I believe brain retraction is used in some approaches and not others..

[JimGagnepain]

I have much to learn on this topic.  And I still have to accept the fact that I have a serious health condition that requires a very complex surgery.  I also know that it will be a long recovery, with a lot of setbacks, and very possible loss of function.  Choices are mine right now, but eventually I'll turn it all over to the Lord.

[LakeErie]

Do not confuse "endoscopic" and minimally invasive. I had minimally invasive surgery at the Cleveland Clinic and the surgeon, Joung Lee, had performed over 1000 skull base surgeries with the method, both meningiomas and schwannomas ( more than 600 of the latter.) My surgery entailed no endoscopes at all, only microsurgery through a quarter sized opening.
Another poster here previously had minimally invasive surgery for her AN at UCLA with Dr John Frazee at UCLA with good results and I believe at that time he had done over 600 such surgeries.
There is a third well known surgeon in Pittsburgh whose name escapes me now who uses minimally invasive techniques. He had at one time been with UPMC but moved his practice to another major hospital.
My surgery, for a relatively large tumor, was over in under 3 hours. The operative report stated 95 - 97% tumor removal. Remnant of tumor was left on facial nerve as it was adhesive. I had no ICU time, was walking the day after, and discharged in less than 48 hours.
I did have significant complications but I feel they were due more to the tumor size than the technique used and the complications have resolved with time.
Dr Lee is no longer with the Clinic, he is now in Loa Angeles.
Again not all minimally invasive AN surgeries are entirely endoscopic in nature and no endoscopes may be used at all.
One last point, because of the size of my tumor, cerebellar retraction was necessary, but my surgeon had no concerns with it.
Hope this helps, and good luck.

[Mlamb]

Dr. John Lee at UPENN does endoscopic surgery. But again it is not less invasive - the incision and the opening in the skull (I believe) is the same- he just uses an endoscope which not all neurosurgeons feel necessary to get the job done.  You can send your scans to him for a free opinion and explanation of the benefits of this tool. . He will call you he is very good in that way.

[JimGagnepain]

Yes, thank you for your very helpful comments and posts.  After meeting with doctors yesterday, I agree with the assessments regarding endoscopic surgery.  Most doctors seems to use the endoscope as needed, or as mentioned - not at all.

At this point, I'm focusing more on procedures used, once they are in there.  Sounds to me, that if nerves are dead, assuming a good competent team of surgeons, it doesn't make much difference.  I'm wondering more about techniques used, if the nerves are alive, and running through the tumor.  From speaking to the docs, it sounds like there's a good chance,"95%", that my facial nerve, "long term", will not be affected, as it lies somewhat outside the tumor.  So that was very good news. Other nerves may be more of a crap-shoot, and for sure, at least one of the two balance nerves is gone, as the tumor grew from it.

[Sparky1962]

To JimGagnepain - I, too, have been researching endoscopic removal of my 3cm AN. I'm currently on a surgery waiting list in Alberta, Canada. My doctors, a neuro-otologist (ear surgeon) and a neurosurgeon only get two operating days a month so it could be a long wait. According to the Acoustic Neuroma Association of Canada, endoscopic surgery is not offered in Canada. I have been in contact this week with the Patient Care Coordinator at the Skull Base Institute in LA. Apparently the endoscopic surgery is only 3 hours long leaving a dime sized bone plug compared to the 8-9 hour open craniotomy procedure that I'm waiting for here which they have to cut the hearing and balance nerves. There is a pre-op visit, surgery which uses a cold laser developed by NASA, two night hospital stay, you hang out in your hotel for the weekend, have a post-op check and usually fly home after 4 days. I'm waiting to get the hard copy of my latest MRI to send to them and then have a Skype consultation with Dr Shahinian (for a $990US fee). I'm doubting my health care insurance will cover the surgery but she couldn't give me a price until they have all the procedure codes after the consultation. I will try and get a ballpark figure before the consultation. With our Canadian $ being in the toilet I'm in for a huge bill!
The SBI has a very good website. Dr Shahinian has been doing surgeries for 20 years with the last 12 of them endoscopically. It sure sounds less invasive with NO cutting of the nerves, less facial nerve damage, less instances of CSF leakage and quicker general recovery time. Makes sense since there is a much smaller hole, NO manipulation of the brain and even the fact that the patient is under anesthetic for a third of the time makes a difference.
Even though my doctors never even mentioned the endoscopic approach in the last almost two years since my diagnosis (I found it by accident on the internet a couple of weeks ago) and are Canadian renowned surgeons, I'm definitely leaning towards this endoscopic surgery!
If any others have had surgery with Dr Shahinian, please share your experience!