Endoscopic Neurosurgery for Brain Tumors in Children

By: The Children's Hospital of Philadelphia

People come to CHOP neurosurgery from all over the world, and I think largely it's because of the success we've had because we do such a team approach. It's not one person, one surgeon, one physician. It's that you're getting a group of world-class physicians that all work well as a team. When we sat down with Dr. Storm, I think one of the things that made us feel so much more at ease was that he was a huge proponent for pushing for endonasal surgery. The lesions we like to remove through the endoscope are ones that are midline, skull based lesions, tumors of the pituitary gland, the stalk, the hypothalamus, boney tumors, chordomas or sarcomas of the clivus or the bones themselves can be resected. The endoscope is a camera that also has a light source on it so we're able to see better inserting the endoscope than we can with a microscope. It gives us better access to the lesion.

We usually have two monitors set up. So we're looking across the table. The endoscope's usually held by the otolaryngologist in one nostril, and I'm able to operate through the other nostril to remove the mass. When we sat down with Dr. Storm, we felt like he was competent, he was confident, and I think even Lucas said it himself that he just made him feel comfortable. And I think that's where we felt like, here's the surgeon that we really want to trust our child's life with. Our son Lucas ended up doing surgery through the nasal, endonasal. But obviously the more traditional way was a craniotomy.

The traditional removal of these tumors were an open craniotomy, which essentially means, a child would have their head shaved here, a large incision over an area of bone where a bone flap, or an area bone would be removed, and then the brain would be retracted till they got to the area of the tumor. The beauty of what we're doing in these specialty selected cases is we're identifying that that back of the sinus, the back of the sphenoid sinus, the tumor's right there. So if we can access it through the sinus, we don't have to go through these large incisions, this large removal of bone, that retraction of brain that all has long-term issues in our pediatric patients. So, essentially what we're doing is we're taking a much smaller hole, the sinuses, where we're using all of our specialized equipment, instrumentation and skillset, to identify the tumor and take it out in a very minimally invasive way.

But you can't just grab the tumor and pull beause if you do, you pull some of the expensive real estate with you. It's really more of a gentle tug. And then as we keep saying dissection, it's our way of moving around that tissue so the tissue will roll out to us. That's the process that takes hours. When we do an endoscopic procedure, there's always a neurosurgeon and an otolaryngologist.

Endoscopic Neurosurgery for Brain Tumors in Children

Oftentimes depending on the case and the severity, they'll be two neurosurgeons and two otolaryngologists if it's a very complicated case, or one that's gonna take several hours. I actually have two of each in there. Our goal is to remove the tumors completely. And that will give the child the best quality of life and the best possibility of a completely normal, long-term life.

Now we're able to come in endoscopically, do this wonderful surgery, and the patients leave without any deficits, and that is a 180 from what was happening before. Generally speaking, when you do an endoscopic procedure, the patients have much less pain, and as a result, are able to leave the hospital much more quickly. They don't have the swelling. They don't have the pain, but they also don't require any retraction of the brain. That's one of the main advantages of doing this is we're not even entering the skull as we have before, and we don't have to retract on the brain itself. We do over a thousand cases a year. One of the busiest, if not the busiest pediatric neurosurgery departments in the country.

We also are diverse. We do a lot of different kinds of operations. But we do enough of them to be familiar, in the hospital, to be familiar with what we're doing. So it doesn't feel like you're getting sent from one doctor to another. It feels like it's a seamless set of doctors who are all taking to each other. People that are dedicated to pediatric neurosurgery in particular, bring a level of competence that can't be replaced. Having a board certified pediatric anesthesiologist who is also specifically trained in neuro-anesthesia and neurocritical care as a part of each patient's delivery of care is incredibly important. When we do these surgeries, it's great to have a team that does a lot of them.

And that's why we've chosen the kind of a team approach. Just not only from anesthesia who do these cases, to the ICU, and to our oncology colleagues, this is a group approach, very collegial, multidisciplinary approach to treat all these patients from first time that they've been diagnosed with the tumor, and then their long-term follow-up is all done by a similar group of people that do a lot of these. There will be three of four of us scrubbed in at any time, sometimes even more, all bringing our skillset to improve the outcome. To go for complete tumor removal. To get that child back in action.

Lucas is now three years out of surgery. He goes to school, he has fun with his friends. He goes on playdates. He plays sports. He fights with his siblings. He says no to me for every other thing that I ask him to do. He's just a typical 11-year-old boy.

That's what makes me grateful. That's what makes me happy. And also that's what gives me hope. We see our own daughters in those kids' faces. From that respect, it's harder.

But I still wouldn't do it any other way. It's just the way you're made is to care about kids. I'd rather have that kid be in there with me or with Dr. Storm, with people who care and people who are good at what they do, because we want to have as many kids have a good outcome as we can. I think that everyone that we work realizes, I mean, what we do, we are privileged to be able to provide care to these children.

And That means a lot to everybody and it's a privileged and you have to earn it.

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