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Ped Brain Treat

Posted Aug 24 2008 1:49pm
FRED J. EPSTEIN, MD: I'm Fred Epstein. And I am the Director of Pediatric Neurosurgery at the Beth Israel Medical Center where we're all standing right now. And what you're going to see is an operation on a child with a brain tumor. This is a wonderful young child, and he has a brain tumor which we are quite sure is a completely benign, non-cancerous tumor. So in other words, if we can remove it completely, he'll live to be 100 years of age.

And as the surgery unfolds, what you're going to do is get an idea of how it takes more than one person, working together, to achieve this. You're going to see how the anesthesiologist, who is specialized in neurosurgical problems, because it takes special anesthesia here, puts the child to sleep.

You're going to see how the technology works in terms of using guidance systems, almost like airplanes use for instrument landings, to show us precisely where a tumor is before we even make the skin incision.

You're going to have an opportunity to see how nowadays, and this is something that we've only been doing for two or three years, we can do a very major life threatening operation, through a very tiny opening, through only making an opening maybe an inch or an inch and a half. And that makes it less life threatening. That makes it possible for a child to recover more quickly and to go home sooner.

And now what we're going to have a look at, and the next thing which is always so interesting to me, Dr. Jallo, who's doing the operation together with me, we work together, will give you an idea of how we diagnose these tumors. You'll see the MRI scans. You will see how tumors are so beautifully diagnosed through this technology. Technology that, 10 or 15 years ago—20 years ago, would have seemed like a complete fantasy.

GEORGE JALLO, MD: Hello, I'm Dr. George Jallo, pediatric neurosurgeon here at Beth Israel Medical Center. What we have here this morning are the MRIs that were done on our patient prior to surgery. He has a tumor in his posterior fascia, which is very common in children, and especially in his age group. He's an 11 year old boy.

On the MRIs that were done this morning, we have three different images in different planes. You have a coronal, sagittal and axial images, all with contrast. You see this tumor that's bright, that's enhancing, probably measure about two centimeters, maybe a centimeter and a half. And then around it is a cyst, it's a fluid filled cavity that's usually associated with the tumor. And you can see that the brain has shifted to the left.

If you look at it on the sagittal—again, here it is—the back of the brain here, in the cerebellum there's this enhancing tumor that we can see. And then the associated cyst with it.

One other view that just helps us better understand exactly where this tumor is. You can see the tumor's on the right side. Tumor's a bright thing. And then here's the cyst, the black density around it.

What we'll do this morning in surgery is approach this using an image guided system to help us localize it, turn a small bone flap, and take out the tumor and decompress the cyst. By removing the whole tumor, the cyst will disappear and his symptoms should improve shortly after surgery.

DR. PATRICIA BROUSE: Hi. My name is Dr. Patricia Brouse. I'm the attending anesthesiologist on this case. We're at the Institute of Neurosurgery, INN. And I'd like to tell you a little bit about this case. We met this patient earlier and thought about what he needs to have as a safe anesthetic. We mostly just wanted to show him what was going to happen and get comfortable with the people who were going to take care of him. We find with the kids, that's really the thing that works the best.

And as maybe you'll see later also, we have a parent try and come in with the kids who are older, over six months, we have a parent come in to the operating room while the child goes to sleep. The reason we do that is to make it more comfortable for the child and also more comfortable for the parents. But obviously the patient is the first choice. We try and pick the parent that is the most calm because I think the job of everyone is to keep everybody calm. And I that what the parents do is reflected in how the child behaves.

Three things that you would need for anesthesia in general are amnesia, so that the patient isn't aware; analgesia, so that the patient doesn't feel any pain; and muscle relaxation, so that the patient stays still in order for the surgeon to be able to successfully complete the operation.

We provide this in a number of ways. And in this patient, for this patient we're able to give him some things through the IV. We'll be able to give him some narcotics before he wakes up, so when he wakes up he'll be comfortable. And we give him a combination of drugs to make sure that he's asleep and has amnesia during the operation, so that there's no awareness.

The kinds of monitors that we have during the case is we monitor his cardiogram, his EKG, to make sure that his heart is beating in a regular rate and rhythm. We monitor his blood pressure and we use a special monitor the size of blood pressure cuff. We also use what's called an arterial line that goes right in the artery, we put in after the patient's asleep. We usually give some medication in the IV to prevent any nausea or vomiting, because I know that's a common complaint that patient's have. And also something just to make sure that they have not really an upset stomach from having had an empty stomach, because it's important for all age patients to have an empty stomach when they first go to sleep.

Nice deep breathes sweetheart. Okay. Thank you dad. Okay? All right. Best of luck. Now take care of your wife. Good job staying calm.

GEORGE JALLO, MD: What we're doing right now is positioning the head in this Seguida head frame. And it just allows us to hold the head steady during the procedure. This way there's no movement of it. And if we do move the table, the head will move with the table. So it fixes the head to the operating room table without any movement in it whatsoever. And for brain surgery, it's really important that when we operate that nothing moves.

These white markers are actually the markers for the MRI that was done this morning. It allows us to use our image guided computer system to help localize where the tumor is in relation to his skin. And we'll see it a little later on when we set up the computer system, how helpful these markers are.

I'm just registering the points to the guidance system and the system's picking up—the camera over there is picking up the marker. And it just registered it. So with this wand, it registers these skin markers with which he had the MRI done this morning. And what we'll do next is just show you that now it's registered.

After it's been registered, now we can take the wand and point anywhere—let me point to—if I point to the ear right there, the MRI's changed. It's gone to the ear. You can see the ear and here I'm pointing. I'm going to go to the nose next. Here's the nose. And as I move this probe, the MRI ch--the images that we see on the MRI change accordingly. So it just allows us to make smaller skin incisions; to know exactly where we are and not have to search around for the tumor. And here's where I think the tumor is and it's telling me exact that I'm correct.

Now since we have the incision marked, I'm going to make the incision in his skin. And we have skin. We have the high speed drill. Just putting—making a small hole in the skull. So I've changed that burr to a bit now. And what this does, I'm going to slip it under that hole that I made and I'm going to turn a flap, a circular flap, around here.

Now I'm going to take the bum flap off. It's cut. I'm just going to peel it out. That's it. There's the bone. It's off. What we're seeing, the bone's off. We have the dura, the covering of the brain, I'm going to point to it right now. Right here, this is the dura, the covering of the brain. Taking the knife right now, I'm just going to make the cut. Taking a pair of scissors now, I'm just going to extend that opening that I did earlier.

I have got the dura open. You can see right now there is some of the brain coming out. And there's a cyst underneath it. There's the cyst, right there. And we'll bring in the scope right now. We bring the scope in. All right, I'm draining the cyst once more. There's the cyst fluid. You can see the brain's relaxing. The brain's relaxed now.

And this is tumor right there. What I'm holding right there is all tumor. Putting a little—I'm just—this is the separation between brain and tumor. Here's tumor. I'm separating it from normal brain and I'm just cutting it away. It feels different; it's also a little harder from—than normal brain. And you can see it. Can you see over here how dark it is compared to the brain over here. Dark there. This is dark and that's normal brain.

And I'm going to just go—I'm going to go around this tumor and see if we can get it out in one piece. I'm just going to peel normal brain from this tumor. Can you see that? Perfect. Again, brain is very soft. The tumor's firm so we can get away with just peeling it out—like shelling it out like a walnut.

FRED J. EPSTEIN, MD: We're in the cerebellum, you know, which is where we saw the tumor to be. And what we've done is the tumor has been completely separated from the normal brain tissue around it. And what we're doing now is just separating the last remaining part of it from the normal brain tissue. And then when that's done, you see this is one of the areas in the brain where it's actually possible to take the tumor out in a single lump. And by doing that, one is much—is really quite assured that a tumor like this won't grow back.

Now I'm going to point to something here for you. This instrument that's moving is mine. This is the normal brain tissue that I'm pointing to here, which is the cerebellum. And this kind of blackened area, you can see how it's a different color, this area from this area, note the dark color here and the color here as compared to the whitish color here. This is the color of tumor tissue. And what's one of the ways we can tell what's tumor and what's normal by a difference in color and texture.

Now if you look, what we're doing here is actually pulling up on the tumor itself. Now you see this is all tumor here. This is agliosis here I think. Yeah, see the color of this. See what they're grabbing now. And look here, just take one second, I want to just show. Look at the color here. Just note that this is kind of a reddish color and this is white. Do you see the difference? This is normal brain tissue and this is tumor tissue. Can you see that? I'm sorry; I didn't mean to—there you go.

Now we just, we're getting there. There. See this other piece coming up? Look, see this? Look at it. Yep. You see, there is comes. See? You see? This is all tumor. Again, note the white color here. See this white color? The grey—that's normal brain color. See it? Can you see it? And that's how you see the differences, you know?

No, this is it. Now we'll see the last bit is still connected. Just one sec. That's all tumor. Can you see that? That's the entire tumor now that's been—now here is the last bit of connection to the brain. Watch how that's going to be coagulated now. That's that little tweezer that's going through it. And there it is. This is it. Send a little piece to the tumor bank also, okay?

GEORGE JALLO, MD: Going to take one last look around. Really no more bleeding around that I can see. This is a hemostatic agent that we're putting on. It absorbs any of the ooze that might be left in the capillaries and it gets reabsorbed in about a week. So it's a very good agent. Now we're going to just start closing—everything that we opened up we're going to close back up.

This is some bone wax. I'm just putting it into the bone itself. And I'll put some more when we close. It just—there's some blood vessels that go through the bone and we're just making sure that they don't bleed with this element. Now right now I'm just, again, just putting—closing the dura just to prevent any fluid from leaking out. I'm just filling up the brain before we close it. Filling it up with fluid so we can get the air out. If you leave air in the brain they get a little sick after—they just feel a little naus—they feel like they want to vomit or seasick.

This is a little glue. It just seals the closure that we did, the dura. Again, that surgery seal, it's a hemostatic agent and it just helps seal the dura and it gets reabsorbed in about seven days. It just keeps any fluid from leaking or—and helps form a blood clot on it.

GEORGE JALLO, MD: All right, so we've got two plates ready to go. Flap goes right in there. Let's have a screwdriver. The plate. Now we're just going to screw it in. And that's it. Solid. Okay.

Now we're going to start closing. The bone's back. Now we just close back the skin the way we put it back—cut into it. Now we're on the skin—we're closing the last layer right now with, this is a nylon stitch. It'll probably have to come out in like 10 days' time. But that's the only stitch he'll see. All the others were underneath the skin and not visible to the naked eye. Cut. Good. And there you go. That's your incision.

We just finished the operation this morning and it went very well this morning. Using our image guided system, we were able to exactly map out where the incision was going to be, where the tumor was. We were able to make a small incision today, a small opening, probably the size of a half dollar, and be able to take out the tumor, which was probably twice that size. We really had no problems in the sense that we had no bleeding. There was no unforetold complications that we had with the case. Got the bone back with the plating system and was able to close him up with the sutures. I think he'll probably go up to the ICU now for the next 24 hours and we're just going to keep an eye on him, just observe his vital signs, make sure he doesn't develop any delayed bleeding. And just keep an eye on him for infection. And if he feels well, hopefully be able to have dinner tonight and be running around to the playroom tomorrow.

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