Endoscopic Surgery

[gedavis]

I have read all the information in the internet and their Facebook page that I can find, not much sadly.  Does anyone aside from what little is on this forum have experience with Endoscopic Surgery?  It really sounds like the best way to go at this point. 
I know it is relatively new...not sure exact start of it but knowing he has his own business and started off doing the regular surgery makes it attractive as an option.

What is worrisome is that its not an option even mentioned by House, Mayo, etc etc et.........

[Blw]

Mentioned it to my doctor and he was not a fan.

[gedavis]

I really wonder why.   I had a similar procedure done in 2009 on my back for protruding discs.  Small 3 inch incision, use of the fiberoptic camera while the doctors looked at the monitor and performed the surgery.   It appears this Skull Base place has been doing these since 1996 - 20 Years seems like a long enough time to offer it to patients - unless surgeons just want our business??

[Sheba]

Hi.

I asked a neurosurgeon about Shahinian's fully endoscopic method -
He said that the problem with fully endoscopic is, the surgeon does not directly view the inside of your brain - they are only seeing what's showing via camera on a computer screen  Apparently it's possible to nick a blood vessel causing a bleed, and not see it on the screen.   This surgeon was highly skeptical that you should do AN surgery without direct visualization of the entire area being worked on.

However I just got off the phone with someone who had a huge tumor removed in 1988 via microsurgery, with a very difficult recovery, and the tumor grew back later;  In 2007 she went to Shahinian, who was able to operate on her in a relatively short procedure (3 hrs anesthesia) - she felt good about what he was able to do for her.   She questioned this risk of the bleed, since there are several brain surgeries, like pituitary tumors, which are only done via endoscopic method today.

Apparently though, accessing an AN is relatively easy compared to most other brain tumors, so it may be a risk tradeoff thing - the risks may be more in favor of endoscopic technique for tumors in even more delicate locations such as pituitary; but for ANs, it seems like most docs feel microsurgery is the right way to do a removal.   It could be though that this is just how they were trained.

Welcome to the many nuances of researching your options !

[ANGuy]

Apparently though, accessing an AN is relatively easy compared to most other brain tumors

It is my understanding that the exact opposite is true.  Skull-base surgeries, like AN's, are considered among, if not THE, most difficult surgeries that are performed in all of medicine.

[Blw]

Agreed. My doctors told me that is part of what makes these surgeries so long, and it you watch on you tube, it's not just cut a chunk of skull off then reglue. They actually slowly grind it down with a bur until they are through. Closing is not easy either as they have to irrigate well because bone dust can cause problems. They then use filler, cement, and mesh. I think the average is around 7 hrs, which was a big factor in my choosing an alternative, but much longer, 9-11-14 hrs are not unusual. It looks like what it would be if you had to pull gum off a straw, if it was dropped in down a drain. Very tight working space and a lot of times finding the nerves can be very difficult.

[mcrue]

Dr. Michael Seidman said it was like trying to remove a wad of wet toilet paper without tearing it apart. If you tear it apart, so goes the facial nerve.

[rupert]

Many years ago there was this same discussion on this forum.  You should be able to go way back and read those discussions.   If this was a viable treatment option,   you would see it mainstream after all these years.  It hasn't happened,  thus  a lot of questions.   It's been a lot of years but, seems he was a plastic surgeon doing brain surgery and there were a bunch of lawsuits,  so do your research carefully.

[gedavis]

I had searched and did not see that!!! Wow.  Interesting.  I appreciate that information and if anyone has more like it, please let me know. 

[leapyrtwins]

Endoscopic removal of ANs isn't widely done.  The reason is that it's impossible to see a brain bleed during an endoscopic procedure - and while that's something that doesn't happen frequently - it's a risk most doctors won't take (as it can be a very dangerous situation).  Only doc I ever heard of who does endoscopic is Dr. Shananian @ Skull-Based Institute.  A few people on the Forum have been to him and liked their outcomes.  Dr. Shananian is a somewhat controversial doctor, but outside of that I don't know much about him.  Search (use the search box on the upper right side of your screen) for Shananian, Skull-Based Institute, or endoscopic and you can probably pull up some old posts. 

Best,

Jan

[sharonov]

This subject may be dead, but in case it's not:  not only does Medicare not approve Dr. Shahinian, but his license has been revoked.

[ANSydney]

Aren't there others that do fully endoscopic surgery on acoustic neuromas?

[sharonov]

There's a Dr. Jho in Pittsburgh, but he doesn't do enough acoustic neuromas to satisfy me.  I liked the idea at first, but have opted for retro-sigmoid with Dr. Friedman in L.A. because he and his partner do so many.  There is nobody that I know of who does a lot of acoustic neuromas and does them with an endoscope. There must be a reason. 

Re Dr. Shahinian--when I mentioned his name at an AN convention, the doctors in attendance were unanimous in calling him a danger.  Several who practiced in L.A. said they could practically start a practice just by treating the patients he had screwed up.  That said, I talked to one woman who was very pleased with what he had done with her.

[ANSydney]

This is a real pity, since Shahinian's paper entitled "527 Full Endoscopic Resection of Vestibular Schwannomas" http://fhs.mcmaster.ca/neurosurgery/documents/s-0031-1275335-acoustic.pdf from 2011 was encouraging. The results are reported as:

"Utilizing the fully endoscopic technique, 94% of tumors were completely removed; subtotal removal was performed in 6% of patients in an attempt to preserve their hearing.  Anatomic preservation of the facial nerve was achieved in all of the patients. Functionally, measurable hearing (serviceable / some) was preserved  in  57%    of  cases  that  had  either  “serviceable” or “some” hearing  pre-operatively.   There were  no  major  neurological  complications  such as quadriparesis, hemiparesis, bacterial or aseptic  meningitis,  permanent  lower  cranial  nerve  deficits, or deaths."

This looked good, however now the credibility of the information is in questions. If it is questionable, how could the paper be published in the journal Minimally Invasive Neurosurgery? This has even wider implications in the credibility of any publication!

Looking for balance, I examined, "Facial Nerve Outcome after Vestibular Schwannoma Resection: A comparative Meta-Analysis of Endoscopic versus Open Retrosigmoid Approach" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4375046/ published November 2014.

It states "Good facial nerve outcome was achieved in 67% of the open series patients and in 94% of the endoscopic series patients. Other outcomes in the open and endoscopic series were the following: gross total resection, 91% versus 97%; functional hearing, 22.6% versus 46%; wound infection, 1.3% versus 2.6%; and recurrence, 5.4% versus 2.2%"

Not mentioned in the abstract, death was at 0.9% for open surgery, versus 0% for endoscopic.

Also, "Endoscopic Resection of Vestibular Schwannoma" published January 2015 https://www.ncbi.nlm.nih.gov/pubmed/26225307 ; admittedly, for only 12 patients.

The results were "All patients successfully underwent gross total resection. Facial nerve preservation rate was 92% with 11 of 12 patients retaining an HB score of 1/6 postoperatively. Hearing preservation rate was 67% with 8 of 12 patients maintaining a stable AAO-HNS grade and GR score at follow-up. Mean tumor size was 1.5 cm (range: 1-2 cm). No patients experienced postoperative cerebrospinal fluid leak, infection, or cranial nerve palsy for a complication rate of 0%. Mean operative time was 261.6 minutes with an estimated blood loss of 56.3 mL and average length of hospital stay of 3.6 days" and the conclusion "A purely endoscopic approach is a safe and effective option for hearing preservation surgery for vestibular schwannomas in appropriately selected patients"

There is a more recent paper, which is not at my fingertips, which states that in order for surgery to remain competitive with radiosurgery, new techniques, including endoscopic, need to be explored.

Maybe we shouldn't throw the baby (fully endoscopic surgery) out with the bathwater (Dr Shahinian).

[sharonov]

I agree.  When I talked to Dr. Shahinian, that's just about the same opinion I expressed at the time, that maybe all the other surgeons don't like what he's doing because it's new and doctors never like new things (unless they have invented them.)  I'm about to have retro-sigmoid, which I've avoided for 6 years, and I wish that one of the doctors who did these on a regular basis had moved to endoscopy.