Brain surgery, even when using masterly surgical techniques, is fraught with risk: this crucial organ is too delicate and complex for complacency. Professor Robert Reisch, one of the leading neurosurgeons in Europe and the world, offers help with latter-day methods of endoscopic and minimally invasive surgical techniques that can solve problems without adding new ones.
– Today we are talking about minimally invasive brain and skull operations. Any intervention in this area of the body carries enormous risks…
– Yes, therefore it is important to meticulously approach the issue of planning an operation. Even minor complications can lead to a deterioration in the patient’s quality of life. During the operation we focus on the removal of the tumor as accurately and precisely as possible, but always with our global goals in mind – ideally, the complete recovery of the patient.
– What does your method, for which so many patients clamour for your services, consist of?
– The basis of our concept is to use careful methods, causing as few injuries and inconveniences to the patient as possible. We don’t even shave off the hair on the head before the operation, so as to treat the soft tissues with care, and we use minimal skull opening. Our main task is to cause as little damage as possible to the normal brain tissue. In the past, neurosurgeons used extended trepanation, and, of course, a large cortical surface would be damaged during the operation. The brain was fixed in place for several hours with retractors, which caused additional approach-related injury of the sensitive tissue. Today we are able to save as much brain tissue as possible. Using endoscopic and minimally invasive methods, it has become possible also to carry out complex operations through even the nose or a limited eyebrow skin incision.
– What are your requirements for infrastructure and equipment?
– The results of minimally invasive brain surgery depend greatly on equipment and infrastructure. We make use of equipment for obtaining three-dimensional endoscopic images, intraoperative computed tomography, intraoperative angiography, and neuromonitoring. Teamwork also plays an important role. In difficult cases, we seek the help of our colleagues: specialists in other disciplines. For example, in neurovascular cases, we cooperate closely with our colleagues in interventional neuroradiology. Complex surgery through the nose is always performed together with an experienced rhinologist.
– What diagnoses do your patients come to you with?
– Brain tumors and metastases, skull base tumors, pituitary adenomas, meningiomas. Patients with vascular lesions, such as angiomas and aneurysms, are also frequently treated in our clinic. We always operate on hydrocephalus and complex cystic lesions purely with endoscopic techniques.
– I remember a case – a woman found out she had a brain tumor and went for treatment in the USA. There she was offered chemotherapy. Do you think it would be possible to resort to surgery in her case?
– No question – there are inoperable tumors and non-surgical cas es. For example, with lymphomas and germinomas we offer only a biopsy, frequently with an endoscopic procedure and recommend a radio-oncological treatment.
With malignant tumors we want to achieve a high-quality resection of the tumor, then we prescribe valuable adjuvant treatment and rehabilitation, thereby improving the patient’s quality of life and increasing their life expectancy.
As for benign brain tumors and lesions of the skull base, we can often offer curative treatment with radical resection. In these cases it is especially important to offer the best possible surgical treatment in a safe and gentle way, by using minimally invasive techniques.
– I became acquainted with your work through one of these cases. A young journalist from Ukraine had two surgical operations before she came to you. Why didn’t she have the tumor removed during the first operation?
– Yes, only a small part of her tumor was removed. The surgeon either acted too carefully or applied inappropriate methodology. In some cases, a lack of modern techniques leads to a suboptimal surgical result.
Yes, the doctors told the aforementioned patient that they did not have normal microscopes and instruments. And this was in a big clinic!
Modern neurosurgery is expensive. Equipment such as modern surgical microscopes, instruments, and endoscopes are not available everywhere. We routinely use neuronavigation and intraoperative imaging with CT and MRI scans, and electrophysiological monitoring in cranial surgeries.
When operating on malignant tumors, we use a special fluorescence-guided resection, and the necessary contrast agent alone costs $1,700. But in many countries, health insurance covers only about $2,000 dollars for brain surgery, and that includes the procedure itself, the postoperative care, and the rehabilitation.
– In your opinion, is a regular preventive examination of the brain necessary?
– Each person has the right to decide for himself whether he needs an image of his brain so that he might notice a disease before it begins to cause him inconvenience. There are people who, as part of a regular check-up, do an MRI of the brain and CT of the whole body. We know that with any type of tumor, whether it is a benign or a malignant tumor, early recognition is crucial. If a tumor is detected early enough, the patient has a chance of recovery. If the tumor is detected too late, when metastasis has already appeared, there is almost no chance of recovery. Therefore, today there are a lot of discussions on this topic. However, there are no evidence-based data on the necessity of preventive examinations.
– Is it always necessary to immediately operate upon the accidental detection of a tumor during such a routine examination?
– Generally, we compare risks of treatment with the risk of the natural history of the incidental lesion. Several details influence the decision: where the tumor is situated, how large it is… Is it a dangerous location or not? What is the supposed diagnosis? Is it a slow or rapidly growing lesion? Is it benign or malignant? The patient’s age is also important, as is his general condition and attitude – whether he wants to be treated or not. However, we do not operate on every incidental finding! In several cases we emphasize a “wait and see” management approach and recommend regular MRI controls. According to progression or clinical deterioration, we clearly offer active treatment. In addition, in every single case, it is a team decision. An oncological plan is drawn up, which reflects whether we treat the patient or not, and if we do, what the treatment will be. Of course, an individual approach is also very important. Patients today are better informed, and they can form their own opinions. It is also important to get a second opinion. I personally often recommend my patients visit other specialists to find out their opinion on the disease and treatment methods. The patient can decide for himself whose advice to follow. People today are more aware of such things and are more ready to bear responsibility for their decisions.
– Has the statistics on such operations changed compared to the 1980s and 90s?
– Of course. They have changed even over the past 10 years, especially in two aspects. The first aspect is surgery planning. With modern imaging, we can plan the surgical procedure accurately and we don’t have to find the lesion during surgery. The second important point is our infrastructure and surgical tools. With better visualization – using microscopes and endoscopes, neuronavigation, and intraoperative images we achieve today far better results than we did 20 years ago.
– Can you call yourself a pioneer in this area?
– Professor Axel Perneczky in Mainz, Germany, was a pioneer in endoscopic and minimally invasive neurosurgery. He was my teacher and mentor. I learned a lot from him. Together with my partner Professor Nikolai Hopf, we have continued his work and established a postgraduate education center, ENDOMIN College. We organize several courses in the field of neuroendoscopy.
– We know that smokers are an at-risk group for lung cancer. Are there any similar factors when we talk about brain cancer?
– None. Numerous studies have been conducted on the relationship between the effects of mobile phones and the occurrence of a brain tumor, but there are no conclusive results proving a connection.
– How long did the longest operation in your practice last?
– More than 20 hours. But lately, that sort of operation has become a rarity. Now the average operation time is 8-10 hours.
– How do you keep fit to bear the strain?
– I exercise regularly, a 30-minute workout every morning. However, it is important to me that I can concentrate and a working atmosphere reigns in the operating room. When you are supported, you forget about the time and do not notice how long the operation is taking.
– When patients come to you for surgery, how can they evaluate the average time of their stay here after the surgery?
– Typically, the patient is discharged on the third to fifth day after surgery, but in individual cases, it can be longer.
– Do patients need to undergo an additional examination at your clinic or is it enough to bring results from their doctors?
– It will also be necessary to undergo an examination since we use special equipment, and we can get a clearer picture of the disease. Also, patients often come with old pictures, but it is important for me to have recent ones.
– Telemedicine (or Telehealth) is getting more and more popular now: people (usually from a major city such as Moscow, Dubai, or Astana), ie a doctor and his or her patient, seek consultation from another doctor abroad. Do you have Telemedicine?
– Yes, of course. Today it has become very convenient to exchange electronic data. Often, colleagues send me pictures of patients, and I make up my mind about the state of their disease. The patient can come and get acquainted with me or I can send him my opinion. Today everything is possible.
– Should the patient’s physician be present at a teleconsultation?
– Not necessarily. It can happen in different ways, and the patient may seek advice himself.
Robert Reisch
Professor Robert Reisch was born in 1971 in Budapest. He graduated from the Medical Faculty of Semmelweis University in Budapest with the highest scientific award, “Pro Scientia“, a prize established by the President of the Hungarian Republic. He was a resident with the famous neurosurgeon Prof. Axel Perneczky in Mainz, Germany, and passed his neurosurgical board examination in 2003. From 2005 to 2008 he was Professor and Vice-Chairman of the Neurosurgical Department of the Johannes-GutenbergUniversity in Mainz. In 2008, he moved to Zurich and in 2010 he established the Centre for Endoscopic and Minimally Invasive Neurosurgery at the Hirslanden Private Hospital. From 2007 to 2014 he was the co-director of international neuroendoscopy courses at Aesculap Academy, teaching almost 500 participants from 29 countries. In 2015, together with Professor Nikolai Hopf, he founded ENDOMIN College.
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