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Endoscopic and Combined Surgical Approaches for Patient Care: Insights and Considerations

This symposium presents an in-depth discussion on the selection of endoscopic and combined surgical methods for treating conditions such as epilepsy and hypothalamic tumors. Led by Dr. Ruth E. Bristol and a panel of experts including Maggie Bobrowitz and Harold Rekate, key topics include the definition and operation of endoscopes, criteria for choosing surgical approaches, and the risks and benefits associated with treatment. Attendees will gain valuable insights into patient selection and management strategies while acknowledging the contributions of statewide sponsors in advancing neurological care.

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Endoscopic and Combined Surgical Approaches for Patient Care: Insights and Considerations

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  1. Symposium for Patients & Caregivers

  2. Endoscopic and Combined Surgical Approaches Ruth E. Bristol, MD Assistant Professor of Neurosurgery

  3. Acknowledgements • Maggie Bobrowitz, RN, MBA • HH team • Harold Rekate, MD • AdibAbla, MD • Patients and Families

  4. Outline • How do we choose the right surgery? • What does “endoscopic” mean? • How an endoscope works • Choosing the endoscopic approach • What does “combined” mean? • Why do we need a combined approach

  5. How Do We Get There? Blow up of lesion

  6. Patient Selection • Type II, III, and IV: Endoscopic + • Type III and IV: Combined

  7. Risks of Treatment • Memory loss • Hypothalamic injury • Increased appetite • Diabetes inispidus • Other hormonal abnormalities • Cranial nerve/ vascular injuries

  8. Risk Spectrum • Lowest Risk • Highest Risk • Gamma Knife • Endoscopic • Transcallosal • Orbitozygomatic

  9. What Is An Endoscope?

  10. Endoscopy • Endoscope approaching lesion from side contralateral to attachment. • Micromanipulator on the endoscope, and stereotactic guidance frame.

  11. Terms • Contralateral • Ipsilateral

  12. Endoscopic • Pros • Comparable seizure control (49% vs 54%) • Shorter length of stays (4.1 vs 7.7 days) • Cons • Short term memory loss • Less working room (bad for large lesions) • Thalamic infarct reported (~85 % asymptomatic)

  13. Endoscopic • Background

  14. Surgery From Above • Endoscopic series • 37 patients with seizures refractory to 3+ AED’s (32/37 started as gelastic) • Mean age of onset approx 10 months of age • 62 % with IQ < 70 • Always a contralateral approach • Preferred when attached to one ventricle • Results Ng, Rekate et al. Neurology 2008

  15. Surgery From Above • Percent of disconnect/resection (measured by blinded radiologist) • Not statistically tied to seizure-free rate • 100% resection gave 100% seizure-free postop course in two-thirds (8 of 12) • Compared to open approach • Shorter LOS endoscopic • 4.5 versus 7.7 days • Comparable seizure-free rates • 49 % vs. 54 % (endo vs. TC) • Tumors smaller in endoscopic • 1.01 vs 2.43 cc (p=0.0322) • Reasons to favor open approach • Larger tumors (>1.5 cm) with bilateral attachments • Better for children younger than adolescent age • 6 mm of space needed between top of tumor and roof of 3rd for endoscope

  16. Seizure control Abla et al., AANS Philadelphia. May 3, 2010

  17. Outcome • Seizure freedom: 29-49% • Seizure Reduction: 55-73% • In older patients, higher IQ correlated with better chance of seizure freedom • Memory loss 8% permanent • Adults had more complications than children

  18. Complications • Postoperative DI • Usually transient (< 1 week). DDAVP given in ICU • Weight gain (satiety center = VMH) • 19% in open TC • Short-term memory loss • Transient • 58 % in TC group / 14 % in endoscopic group (< 2 wks) • Permanent • ~ 8 % in both (2/26 and 3/37) Ng, Rekate et al. Epilepsia 2006

  19. BNI Treatment Paradigm

  20. Conclusions • PROPER SELECTION • No single approach is appropriate or advantageous for all patients • Decisions individualized • Surgical anatomy • Presence of acute clinical deterioration

  21. A Special Thanks To Our Sponsors • Aesculap • Barrow Neurological Institute @ St. Joseph’s Hospital • Barrow Neurological Institute @ Phoenix Children’s Hospital • Great Council for the Improved • Hope for Hypothalamic Hamartoma Foundation • KARL STORZ Endoskope

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