Innovative Doctors + Better Technology = Practice Changess

When Dr. Carrau and researchers at the University of Pittsburgh began performing the endoscopic procedures, cerebrospinal fluid leaks occurred in about one in four patients. The use of the flap immediately decreased the leak rate to 6 percent, and now it is down to 4 percent.

Of the 39 patients treated by his team, 11 operations involved esthesioneuroblastomas. The rest of the procedures included neuroendocrine tumors, adenocarcinomas, melanomas, and various other tumor types. The follow-up ranged from six to 61 months. Currently, 36 of 39 patients have no evidence of disease; three patients died of disease, at six months, 10 months, and 18 months following surgery.

Combining his data with those from the University of Miami, we have 22 esthesionseuroblastoma patients with a mean follow-up of 31 months. We had one conversion to an open approach and two positive margins. All the patients in the series, ranging from nine to 104 months postsurgery, have no evidence of disease. Three patients experienced cerebrospinal fluid leaks, Dr. Carrau said.

Endoscopy Pros and Cons

Dr. Carrau said that another advantage of the endoscopic approach is that the surgeon has better visualization of the surgical field. With microsurgery, it doesn’t matter how big you magnify it-you will get the same structure, he argued. With the endoscope, you can look around the corners.

In performing endoscopic oral cancer procedures, Dr. Carrau noted jokingly, Our philosophy is that you take bone out until you think it is too much, and then you take some more. It isn’t enough to be able to see; you have to work in the area.

He said that the disadvantages of endoscopic surgery include the fact that there is a steep learning curve, the procedures are instrumentation- and technology-dependent, it has a two-dimensional field of view, and there are some reimbursement issues that need to be solved.

Dr. Carrau said that some people might consider the necessity of requiring two surgeons as another disadvantage. However, I see that as an advantage, not really a disadvantage, he said.

The take-home message is that these cases should be handled as a team surgery; surgeons should be trained in both open and endoscopic techniques. Incremental learning is really a key to this type of procedure, he said.

He advised clinicians interested in performing the procedure using endoscopic approaches to go to courses, do various dissections, and work slowly. Keep yourself within the capabilities of your team, he said. When you move into the lateral skull base, you have to have a lot of experience on your team to handle vascular complications so you don’t have a catastrophe on your hands. Institutional support is also key. You need adjunctive, complementary specialists around you, such as interventional radiologists, who can get you out of trouble.