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|NI FEATURE: THE EDITORIAL DEBATE-- PROS AND CONS
|Year : 2016 | Volume
| Issue : 5 | Page : 875-876
Out-patient brain tumor surgery
Satish Rudrappa, Swaroop Gopal
Department of Neurosurgery, SAKRA Neurosciences, Bangalore, Karnataka, India
|Date of Web Publication||12-Sep-2016|
Department of Neurosurgery, SAKRA Neurosciences, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rudrappa S, Gopal S. Out-patient brain tumor surgery. Neurol India 2016;64:875-6
The article by Turel et al., focusing on outpatient brain tumor surgery, presents an interesting perspective to brain tumour surgery in the present times. The prospective advantages of these practices in India and other developing countries are immense as they aim at reducing the economic burden on the patients and their family. We write this article based upon our own modest experience of 40 craniotomy cases in the last 4 years where a “day care procedure” was adopted. This number could have been higher if many more of our patients and colleagues had accepted the fact that it is feasible to conduct brain surgery as a “day care surgery.”
We are passionate about facilitating an early discharge of the patient from the hospital due to various reasons mentioned in the paper, and also to remove a deeply ingrained myth within the population that brain or spine surgery is a major endeavour that mandatorily requires a prolonged stay in the hospital. In our practice, which can be termed “Private – Institutional,” it has been our protocol to call these as “24-hour procedures” rather than naming them as “Day-care” or “Outpatient procedures.” These “24-hour procedures” significantly reduce the patient's financial burden. At the same time, the patient's acceptance for the procedure has become better over time, along with an enhanced departmental and hospital confidence.
An “outpatient or a 24-hour procedure” can be extended both to patients with awake craniotomy and to patients undergoing surgery under general anaesthesia. However, patients undergoing awake craniotomy accept this concept better than patients operated under general anaesthesia. This is probably because the patients undergoing an awake craniotomy have been preoperatively explained in detail about the whole procedure and they are awake throughout the procedure. In fact, it has been our practice to make our patients move themselves from the operating table to the postoperative room immediately after the surgery, thus, imparting in them a dose of extra confidence.
Our indications for awake craniotomy are similar to those mentioned by the authors – lobar tumours, surgery in eloquent area for lesions like gliomas, meningiomas, granulomas, dysembryoplastic neuroepithelial tumour, etc. In patients requiring brain biopsy, pre-operative perilesional edema predicts to a certain extent whether or not the patient can be treated on a “day care” basis. It is well known that, depending on the grading of the tumor and its location, tumor edema might worsen in some patients postoperatively, causing the precipitation of seizures or raised intracranial pressure. We have not included the experience of patients undergoing brain biopsy at our centre in this commentary.
Our exclusion criteria are also pretty similar to that of the authors. In addition, we exclude any patients requiring prolonged surgery in and around the neurovascular bundles, as in the case of patients undergoing surgery for insular gliomas or suprasellar lesions. We believe that with advancements in technology like neuronavigation, intraoperative electrophysiological monitoring, use of intraoperative ultrasound and mobile intraoperative computed tomographic scans, we will be able to perform these kind of surgeries in a much better way, more frequently, and with far greater confidence. Interpatient discussions, preoperative counselling, preoperative video demonstrations of similar procedures, and reemphasizing the “team approach” with the patient and his/her immediate family has helped us in recruiting more patients for this procedure in our practice with better acceptance and cooperation. It is not only the site and size of the lesion which predicts the success of outpatient care surgery; the surgical skills of the neurosurgeon also play a major role. Only the senior neurosurgeons, with a vast experience in tumour surgery, perform this kind of procedure in our unit.
While performing day care surgeries, it is imperative that the extent of craniotomy should be tailored to the lesion, with minimal dissection of the pericranium and muscles. Meticulous inter-gyral surgical dissection under microscopic guidance, preservation of venous channels and proper haemostasis are imperative. All these factors reduce post-operative oedema, seizures and neurological deterioration. None of our patients required any readmission for the above mentioned problems.
The role of the neuroanaesthetist cannot be understated in these procedures. The neuroanaesthetist plays a pivotal role in the pre-, the peri- and the post-operative period. Proper use of ring blocks, use of sedatives-hypnotics, if required, to maintain the patient in a less anxious state during the procedure, and keeping the patient engaged during the procedure without him/her paying undue attention towards the steps of the surgery, considerably help in the surgeon's work. In addition, the anaesthetist's role in conducting the neurophysiological monitoring is invaluable.
In our practice, only about 30% of patients are medically insured and the rest bear the cost of the treatment themselves. The “24 hour procedure” allows us to contain the patients' perioperative costs by minimizing the duration of their postoperative observation in the intensive care unit, by administering a single dose of prophylactic antibiotic, and by utilizing less number of invasive lines. We do concur with the authors about the other benefits mentioned in their article. Most patients feel a sense of 'awe' leaving the hospital in a day and their feedback is heart-warming.
However, we do have problems with patients not accepting to leave the hospital within 24 hours. This may be due to the pre-surgical priming, like the fear of undergoing brain surgery, multiple second opinions, a referring family physician with a poor knowledge regarding brain surgery or recent advances, who does not instil sufficient confidence in the patient and his/her family prior to the procedure. We also find that patients with a higher educational status and who understand the scenario better, often do not accept this procedure as easily as may be expected. This is attributed to the numerous internet searches and extensive reading about their own disease by the patients. Thus, they remain obsessed with the risk of post-operative complications along with their own radiological and histopathological diagnosis.
We assume that as more institutions use this concept, educate other medical professionals about advancements in this field, and introduce public awareness programs, more acceptance might be gained in the society for the “day care procedure.” The increasing tendency to resort to litigation, due to excessive media coverage, may also be avoided by creating awareness regarding the benefits of the procedure.
The bottom line, as in all medical practice, is good clinical judgement. This is the key to success.
| » References|| |
Turel MK, Bernstein. Is outpatient brain tumor surgery feasible in India? Neurol India 2016;64:886-95.