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Improvements in brain tumor surgery

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New developments in neurosurgery Rotterdam 2008
Brain tumor surgery and hemostasis in neurosurgery
Neurochirurgie MTriffaux

Published in: Health & Medicine
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Improvements in brain tumor surgery

  1. 1. Dr. M. Triffaux Dr. V. Marneffe Dr. A. Tyberghien Dr. O. Lermen
  2. 2. Improvements in Brain Tumor Surgery • Advanced neuronavigation – Electromagnetic navigation – Fiber tracking MRI – Neuro Endoscopy • Fluorescence guided resection • Integrat
  3. 3. Hemostasis in neurosurgery • Hemostasis: key importance for successful surgery • Prevention of bleeding is the best solution • Hemostatis methods: – Mechanical – Chemical – Electrical
  4. 4. Prevention of bleeding • Position of the patient gravity is the best allied – head position
  5. 5. Prevention of bleeding • Minimize the risk of vessel injury – Adequate dissection techniques • Avoid to pulling tissue • Maintaining a good visualization – Control powered instrument (drills, Cusa,…) – atraumatic suction tip
  6. 6. Hemostasis in NS • Mechanical – Horsley’s bone wax – muscle stamps, – compression, – ligature, – clamps, – clip: Cushing’s silver clips – cottonoid ,
  7. 7. Hemostasis in NS • Chemical – Historic: alum, copper sulfate, ferric chloride, Zenker solution
  8. 8. Hemostasis in NS • Chemical – Historic: – Organic: oxydised cellulose, gelatin,collagen, autolog fibrin( plasmatic centrifugation) surgicel spongostan surgiflow original fibrillar
  9. 9. Hemostasis in NS • Use of heat to control bleeding has been described throughout human history • Electro surgery Process of electrocoagulation utilizes heat generated from an electrical current that flows through a metal probe to locally burn
  10. 10. Electrosurgery in neurosurgery • 1926 H. Cushing / W. Bovie first removal of brain tumor using electrocautery
  11. 11. Electrosurgery in neurosurgery • 1926 H. Cushing / W. Bovie • 1940 J. Greenwood introduced the concept of two point coagulation, and the bipolar coagulation was invented.
  12. 12. Electrosurgery in neurosurgery • 1926 H. Cushing / W. Bovie • 1940 J. Greenwood • 1955 L. Malis : first commercial bipolarcoagulator
  13. 13. Electrosurgery in NS Monopolar Bipolar
  14. 14. Electrosurgery in NS Monopolar Bipolar
  15. 15. But recurrent problems • Carbonization, charring required cleaning • Thermic lesion surround damage • Sticking adhesion with tissue • get out to clean get in: reorientation • Time consuming • Coagulation failure • Frustration and fatigue for the operator
  16. 16. Solutions • Generator HF computer regulation output types of waves
  17. 17. Solutions • Generator HF
  18. 18. Solutions • Irrigation manual needs assistance automatic adjustable fluid pressure adjustable flow solutions: PL, mannitol, pump
  19. 19. Solutions • Material of the tip: titanium, gold, stainless steel • Coating of the tip: PTFE like Teflon but no miracle solution
  20. 20. Active Heat Transfer technology • Old principle 1942 Now available with minimal profile: Isocool forceps
  21. 21. Heat measurement
  22. 22. In vitro studies
  23. 23. Y. Arakawa and N. Hashimoto Study Jpn J Neurosurg (Tokyo) 14 : 698-705, 2005
  24. 24. Y. Arakawa and N. Hashimoto Study Jpn J Neurosurg (Tokyo) 14 : 698-705, 2005
  25. 25. Y. Arakawa and N. Hashimoto Study Jpn J Neurosurg (Tokyo) 14 : 698-705, 2005
  26. 26. Y. Arakawa and N. Hashimoto Study Jpn J Neurosurg (Tokyo) 14 : 698-705, 2005
  27. 27. My personal experience • Using 1 and 0.5 mm
  28. 28. My personal experience • Procedure : – Vascular – Intracranial tumor – Spine tumor – Cerebello pontine angle
  29. 29. Personal experience • What I do with Iso Cool – More accuracy – More efficiency – More visibility – Less risk – No irrigation – Time-saving
  30. 30. Illustration 1
  31. 31. Illustration 2
  32. 32. Illustration 3
  33. 33. Illustration 4
  34. 34. Personal experience • Limits – Cost single use (300 €) – Profile – Not easy to do without it if you have used it
  35. 35. Advanced neuronavigation • Electromagnetic Navigation • Fiber tracking MRI
  36. 36. • Neuronavigation – Optical system camera tracking instruments – Electromagnetic system single coil gives the position in a electromagnetic field Electromagnetic Navigation
  37. 37. Electromagnetic Navigation • Optical system • Electromagnetic tracking
  38. 38. Electromagnetic Navigation • Optical system • Electromagnetic tracking
  39. 39. Electromagnetic Navigation • Optical system • Electromagnetic tracking
  40. 40. Electromagnetic Navigation • Optical system • Electromagnetic tracking • Advantages – No single use – No metal interference • Limits – Loss of camera’s line of sight – Smal, non invasive – No calibration – Flexible probe – Fero magnetic disturbence – Single use
  41. 41. NeuroEndoscopy in Oncology Ventriculoscopy Pituitary Key hole surgery
  42. 42. • In ventricular and paraventricular tumor management • In Endoscopic Third Ventriculostomy (ETV) – In the same time of supratentorial procedure – in management of hydrocephalus from posterior fossa tumor Ventriculoscopy in Oncology
  43. 43. • Rigid • Flexible Ventriculoscope
  44. 44. • Image Guided surgery – Choice of the best entry point and the best trajectory – Endoscope tracking per operative Advantages of the rigid scope
  45. 45. • Image Guided surgery • Endoscope stability – Pneumatic arm – microdriver Advantages of the rigid scope
  46. 46. • Image Guided surgery • Endoscop stabilisation • Higher quality – optical resolution – trocars: multiple channels Advantages of the rigid scope
  47. 47. Case N° Sex/age (yrs) location Histiological diagnose ETV Further therapy 1 M / 69 3rd V. ant. Pineocytoma II Y No 2 F / 41 3rd V. ant.. Arachnoid cyst Y No 3 F / 72 Occ. paraV. Glioblastoma N Radiation 4 M / 35 3rd V. ant. Dermoid cyst N No 5 M / 21 3rd V. post Germinoma N Radiation Chemotherapy 6 F / 16 Thalamic Astrocytoma III Y Open surgery Clinical data 2003/2005
  48. 48. • 21 yrs , recent diplopia • CT MR imaging: pineal tumor whithout hydrocephalus • Pet methionine: + • Blood  fetoproteine , HCG: nl < 1 mUI/ml • CSF  fetoproteine: nl, HCG:  3 mUI/ml Case N° 5
  49. 49. Case N° 5
  50. 50. • Biopsy diagnosis: germinoma • Treatment: chemotherapy & radiotherapy 2 cycles carbo/ etoposide / Ifosfamide 40 Gy radiotherapy Case N° 5
  51. 51. Case N° 5 Initial MR Post multimodal therapy
  52. 52. Case N° 6 • 16 yrs , Parinaud’s syndrome • CT MR imaging: left thalamic mass hydrocephalus • Pet FDG: – Pet methionine: +
  53. 53. Case N° 6 CT Pet FDG MR Pet met.
  54. 54. Case N° 6
  55. 55. J10 post biopsy & ETVPre operative Case N° 6
  56. 56. • Biopsy diagnosis: astrocytoma III • Treatement: conventional surgery astrocytoma III confirmed Case N° 6
  57. 57. • Acute hydrocephalus needs treatement: – External Ventricular drainage – VP shunt – ETV • In pediatric series: – Majority of the authors advocate ETV prior to definitive surgery – Some others do not justify routine preoperative ETV • In adult patients: there is no specific data Hydrocephalus from P-fossa tumor
  58. 58. Case N° s/age ICP Symp ETV diagnose Open surgery 1 M/46 Y pre Lung metastase Y , radiation 2 F/22 Y pre Medulloblastoma Y , chemo + radiation 3 M/45 Y pre Ependymome II Y 4 M/55 Y pre Gliome II Y 5 F/34 Y pre Melanocytoma Y 6 F/39 Y pre Neurinoma VIII Y 7 M/23 N post cavernoma Y 8 F/56 Y single Breast mets. (3) palliatif Clinical data in adult population
  59. 59. • GA, supine position • ETV with neuroballon • Insertion of a ventricular reservoir • Monitoring ICP 24h-48h with butterfly needle without ventricular drainage Surgical procedure
  60. 60. • Complication: 1 infection (case 8: palliative) resolved with antiobiotherapy • No shunt • No CSF leak after posterior fossa surgery Out come
  61. 61. Fiber tracking
  62. 62. Fiber tracking
  63. 63. Fiber tracking
  64. 64. Fiber tracking
  65. 65. Fiber tracking
  66. 66. Fluorescence guided resection COO - NH3 +CH2C CH2 CH2 O HC N NH VM M P MP V M CH N CH NH HC 5-aminolevulinic acid Protoporphyrin IX Enzymes of heme biosynthesis Intratumoral synthesis
  67. 67. Multicenter, Randomized, Balanced, Parallel, Controlled, Phase III Study: Fluorescence-Guided Surgery Using 5-ALA Patients with malignant gliomas • Surgical candidates • Tumor potentially resectable • Karnofsky Index ≥ 70 • Age 18 - 75 • Primary surgery • Informed consent “White light group” Conventional microsurgery +Radiotherapy “ALA group” Fluorescence-guided resection +Radiotherapy Sponsor: Medac, Germany
  68. 68. n (%) 139 (100) 131 (100) ≤ 55 years (%) 45 (32) 43 (33) > 55 years (%) 94 (68) 88 (67) Median (years) 60 59 “Low” [ 70, 80 ] (%) 28 (20) 31 (24) “High” [ 90, 100 ] (%) 111 (80) 100 (76) No (%) 65 (47) 54 (41) Yes (%) 74 (53) 77 (59) WHO °III (%) 4 (3) 5 (4) WHO °IV (%) 135 (97) 126 (96) ALA WL Demographic Characteristics: Intent to Treat Age KPS “Eloquent” Histology
  69. 69. Complete Resections on Early Postoperative MRI 0 25 50 75 100 Percentage ALA WL 35% 47/131 p < 0.0001 chi2 65% 90/139
  70. 70. 139 104 59 28 16 8 131 85 28 13 7 5 Progression-Free Survival (Intent to Treat) Stummer et al. Lancet Oncol. 2006;7:392-401. Progression-freesurvival(%) 100 90 80 70 60 50 40 30 20 10 0 Log rank p = 0.0078 5-aminolevulinic acid White light Time (months) 0 3 6 9 12 15 Numbers at risk 5-aminolevulinic acid White light
  71. 71. Fluorescence guided resection

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