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|NI FEATURE: THE EDITORIAL DEBATE-- PROS AND CONS
|Year : 2016 | Volume
| Issue : 5 | Page : 877-879
The present status and future possibility of day care neurosurgery in India
Department of Neurosurgery, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
|Date of Web Publication||12-Sep-2016|
Department of Neurosurgery, Apollo Specialty Hospitals, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ghosh S. The present status and future possibility of day care neurosurgery in India. Neurol India 2016;64:877-9
“Day care surgery” is a well- accepted procedure, and many times, the choice of surgeons and patients in the specialties of ophthalmic surgery, general surgery and orthopedic surgery. Apollo Hospital has a dedicated day care center at Chennai, and so have a few health care providers in many parts of the country. A few consultants specialize only in those surgeries that are day care procedures and have been doing these procedures safely with a good outcome over the years. This practice is in a sharp contrast to the earlier years, where due to many logistical constraints, even diagnostic procedures were only available after an overnight admission and workup. This gradual change to day care surgery has been driven by many factors that may be categorized as technological advancements, skill accumulation over the years by individual surgeons and institutions, and the emergence of better-informed patients.
Day care neurosurgery is the practice of admitting a neurosurgical patient in the morning of the procedure and discharging him/her the same evening before 9 pm. The specialties like ophthalmology and general surgery, that developed earlier on in India, had a head start in this field. Apex specialties like cardiac surgery and neurosurgery are also likely to be compelled, or will on there own, take the way of day surgery due to the current prevelance of a multifactorial cascade.
| » Neurosugery: the Final Frontier|| |
The specialty of neurosurgery, more than any other medical subspeciality, is technology driven. The earlier neurosurgeons paved the way for the adoption of technology in diverse fields, within and without the narrow corridors of core neurosurgery. Robotic surgery is becoming a major method of performing procedures, and was initially developed with the aim to treat neurosurgical ailments. In the earlier times, neurosurgery was often conducted on awake patients. Later on, 'awake neurosurgery' developed as a subspecialty of neuroanaesthesia to tackle the unique problems of brain swelling and to adopt to the unique tissue characteristics of the nervous system. The introduction of steroids by Lyle French in the neurosurgical treatment along with development of advanced imaging and localization techniques, such as, functional magnetic resonance imaging, diffusion tensor imaging, operation theatre technology, operating microscopes, microsurgical techniques and newer surgical corridors, have all contributed to the growth and acceptability of neurosurgery, and have considerably improved outcomes. The current era of minimally invasive approaches, image guided navigation, retractor-less surgery, neuroprotective adjuvants and ever-increasing dependence on perioperative neurophysiological monitoring is allowing us to achieve better outcomes with a lot less effort. Stereotactic biopsy has been an early neurosurgical operation in which the patient has been considered as a candidate for a day procedure. This practice has been carried out for some time at certain centers in India.
Awake craniotomy has had a recent surge in popularity and understandably so, as it allows the surgeon to have a much greater confidence in the resection of lesions situated in an eloquent area and ensures much better outcomes. The normal haptic and visual feedback which the neurosurgeon normally utilizes, is taken to a much greater height with a functional and real-time interaction with the patients. Awake neurosurgery has been there for considerable time; currently, a few pioneers have been bringing skull base and vascular surgery into its gambit, thus improving outcomes following these procedures. This gives the neurosurgeon more confidence and greater control. Improving outcome of patients is the ultimate aim of all advances and skills that the neurosurgeon takes years to acquire.
The provocative article by Mazda Turel and Bernstein explores the future of day surgery for patients with brain tumor. They present the case for applying inclusion and exclusion criteria for day care neurosurgery. The senior author pioneered a pilot feasibility study in 1996, the results of which were published in 2001. The authors propose that high volume centers in India can and should treat a subsection of patients with brain tumors with all the care centered on sending them home the same day on which the surgery had been performed. The authors appreciate that awake craniotomies, minimally invasive procedures and routine electrophysiological monitoring are changing the way neurosurgery is practiced today. The paradigm shift has occurred due to the emphasis on improved imaging and applied navigational cababilities permitting minimally invasive approaches and trajectories, no retractor usage and haptic and functional real-time feedback. The need to increase the number of these patients who are undergoing day care neurosurgery should not compromise on achieving maximal possible resection with the best possible outcome. Due to the unforgiving nature of a decompensated nervous system even a simple neurosurgical procedure like evacuation of a chronic subdural hematoma can have devastating complications.
To those of us who are fortunate to have set up a comprehensive theatre facility to perform these awake procedures, the possibility of advancing our specialty are enormous. Dedicated neuroanaesthetists, who understand the nuances of awake craniotomy, will have to continue refining techniques, publish, and train their colleagues the tricks of the trade.,
The normal response in the beginning is that there will be a great increase in the stress on the surgical and the anesthesia teams. This stress is rapidly overcome as the experience and numbers of procedures increase. Standardization of techniques, having to do the same thing over and over again and application of the checklist manifesto to avoid missing anything important, eventually removes all the initial doubts. The key steps in the protocol have to be modified according to the needs of the Indian neurosurgeon, institution and even the city he practices in.
The complications that we can reduce are unlikely to reach the magical number of 'zero.' While acknowledging the facts that a day care procedure will lead to saving of hospital costs, improving patient comfort and decreasing the incidence of nosocomial infections, we are unlikely to convert in large numbers, major intracranial surgeries into outpatient procedures in the near future.
The authors do emphasize that having a complication in a controlled hospital setting is a very different thing than having it at home and sometimes the delay is irredeemable. They tabulate the results of various studies published that cite a complication rate of 18%. This cannot to be ignored. Day care neurosurgery for spinal neurosurgical procedures is not infrequent and still has medico-legal hurdles. The cranial procedures that could be done with acceptable risks are, yet to be ascertained.
Consensus must be reached among the neurosurgeons regarding the procedures that could be included as a 'day care procedure' and these will also vary according to the expertise of individual neurosurgeons and institutions.
This day care revolution, in order to sustain itself, will require the creation of dedicated teams of neurosurgeons, neuroanaesthesists, neuronurses and councilors who will make sure no mishaps occur. The majority of Indian patients who come to large volume centers arrive from peripheral far-flung areas and even these patients could be discharged after the day care neurosurgical procedure to a facility which is less than an hour away in peak traffic from the hospital. Dedicated transfer teams and ambulances that are appropriately equipped could mitigate the complications that may occur due to the delay in returning to the hospital setting.
Thus, like the work of Gupta et al., who did a controlled prospective randomized trial comparing awake craniotomy with surgery under general anesthesia for intrinsic brain lesions in eloquent areas in 53 patients, all large volume centers, both government and private, must collate and pool good quality data on day care neurosurgery procedures and measure the outcome and quality parameters, to arrive at a consensus on which patients can be operated in an outpatient day care setting. The waiting period in large institutions in India runs to a few months for hundreds and thousands of patients. This is unacceptable and so this parallel treatment path will enable a large number of patients with brain tumors to get treated early. Patients whose condition and pathology can only be treated in an in-house setting will also get to the theatre in time. As the technology improves and experience in carrying out these procedures accummulates, we will be able to better categorize neurosurgical patients into the two streams-those requiring day care surgery and those requiring prolonged in-patient stay in the hospital.
| » References|| |
Gadhinglajkar S, Sreedhar R, Abraham M. Anesthesia management of awake craniotomy performed under asleep-awake-asleep technique using laryngeal mask airway: Report of two cases. Neurol India 2008;56:65-7.
Sinha PK, Koshy T, Gayatri P, Smitha V, Abraham M, Rathod RC. Anesthesia for awake craniotomy: A retrospective study. Neurol India 2007;55:376-81.
Gupta DK, Chandra PS, Ojha BK, Sharma BS, Mahapatra AK, Mehta VS. Awake craniotomy versus surgery under general anesthesia for resection of intrinsic lesions of eloquent cortex – A prospective randomized study. Clinical Neurology and Neurosurgery 2007:109;335-43.