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Outpatient Neurosurgery in Neuro-Oncology

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Outpatient Neurosurgery in Neuro-Oncology NEUROSURGICAL FOCUS Neurosurg Focus 44 (6):E19, 2018 Outpatient neurosurgery in neuro-oncology Miguel Marigil, MD, PhD, and Mark Bernstein, MD, MHSc (Bioethics), FRCSC Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada Technological breakthroughs along with modern application of awake craniotomy and new neuroanesthesia protocols have led to a progressive development in outpatient brain tumor surgery and improved surgical outcomes. As a result, outpatient neurosurgery has become a standard of care at the authors’ center due to its clinical benefits and impact on patient recovery and overall satisfaction. On the other hand, the financial savings derived from its application is also another favorable factor exerting influence on patients, health care systems, and society. Although validated several years ago and with recent data supporting its application, outpatient brain tumor surgery has not gained the traction that it deserves, based on scientific skepticism and perceived potential for medicolegal issues. The goal of this review, based on the available literature and the senior author’s experience in outpatient brain tumor surgery, was to evaluate the most important aspects regarding indications, clinical outcomes, economic burden, and patient perceptions. https://thejns.org/doi/abs/10.3171/2018.3.FOCUS1831 KEYWORDS outpatient neurosurgery; awake craniotomy; early discharge; brain tumor EUROSURGERY has been exponentially evolving dur- criteria, in which a patient arrives at the hospital on the ing the last 50 years.1,25 Development of tools such morning of the procedure and, regardless of the anesthesia as neuromonitoring and neuronavigation, along technique used, the patient leaves the hospital the same Nwith the implementation of new neuroanesthesia proto- day before 9 PM, after a specific clinical and imaging as- cols, have helped to shorten surgical times and enhance sessment.7,12,17,24,53 With this system, patients avoid an over- postoperative care, enabling more rapid recovery and early night hospital stay and can start their recuperation outside discharges.30,44,52 All of these improvements have led to a a health care facility.12 redefinition of the primary goal of care in neuro-oncology, The goal of this paper was to review the evolution of with the aim of preserving neurological function and ulti- outpatient brain tumor resection and evaluate its current mately offering the patient a better quality of life.16,26, 31, 39,57 applicability in modern neurosurgery. Consequently, there has been a switch toward less invasive surgeries now, centered on the patient’s perceptions and Outpatient Neurosurgery well-being.8,14,31 The advent of awake craniotomy allowed neurosurgeons Awake Craniotomy: Historical Background, Anesthetic to perform safer maximal resections and decrease postop- Development, and Applicability in Outpatient Setting erative deficits.20,21,29,46,48,50 Outpatient brain tumor surgery Over decades the main goals in neuro-oncology have became part of the neuro-oncology armamentarium after been as follows: to optimize the extent of resection and awake craniotomies were introduced and perfected.32 This to preserve neurological function and patient’s quality of concept was subsequently developed, demonstrating that life.37,46–48,50 The breakthroughs achieved since the 19th this technique can be safely applied, with improved surgi- century in the knowledge about cerebral location and cor- cal outcomes and decreased morbidity compared to cra- tical mapping, along with the introduction of local anes- niotomies performed under general anesthesia.7,44 Outpa- thetics and sedatives, led to the implementation of mod- tient or same-day surgery brain tumor resection is defined ern awake craniotomies.15,29 These procedures have their according to a clearly stablished protocol and inclusion roots in early epilepsy surgery and in the excision of le- ABBREVIATIONS DSU = Day Surgery Unit. SUBMITTED January 19, 2018. ACCEPTED March 26, 2018. INCLUDE WHEN CITING DOI: 10.3171/2018.3.FOCUS1831. ©AANS 2018, except where prohibited by US copyright law Neurosurg Focus Volume 44 • June 2018 1 Unauthenticated | Downloaded 09/29/21 05:33 PM UTC M. Marigil and M. Bernstein sions seated in anatomical regions close to eloquent areas value of cortical and subcortical mapping for decreas- within the brain.15 ing postoperative deficits while improving the extent of Awake craniotomy has been evolving over the last 2 resection and overall survival in low- and high-grade decades. Several factors can be identified as key principles gliomas.18,20,34,46–48,50,51 Eventually, a meta-analysis pub- for this evolution: neuroanesthesia development, improve- lished in 2012 examining the usefulness of intraoperative ment in microneurosurgical technique and management mapping showed that this technique is associated with a of intraoperative seizures, and finally the significance reduction in late (more than 3 months after surgery) post- of brain plasticity for tumors near eloquent areas.6,11,29,30 operative deficits in adult patients with supratentorial infil- Regarding neuroanesthesia and surgical techniques, the trative gliomas, compared to patients in whom brain map- advent and subsequent implementation of remifentanil ping was not used during surgery; this method assumed a plus propofol and/or dexmedetomidine as the anesthetic transient increase in temporary deficits within 3 months regimen linked to the current cortical-subcortical map- of surgery.21 ping and neuronavigation methods have contributed to In conclusion, awake craniotomy with intraoperative the success of awake craniotomies.4,6,11,21,29,30,42 Interest- mapping of brain functions represents the standard of care ingly, in their paper published in 2015, Hervey-Jumper et in glioma surgery near eloquent areas, because this tech- al.29 describe the evolution of awake surgery and include nique increases the surgical safety and does have a posi- a comprehensive analysis of technical recommendations tive impact on neuro-oncological outcomes by increasing in challenging patients: 2-stage surgery (asleep-awake) the extent of resection and overall survival. for tumors with severe mass effect, introduction of the laryngeal mask to control hypercapnia in obese patients Rationale for Outpatient Brain Tumor Surgery or those with obstructive apnea, iced Ringers solutions to There has been a progressively universal trend toward control intraoperative seizures, tailored craniotomies in minimizing the physical and psychological impact that reoperations, and baseline neurological evaluation before surgery can have on oncology patients. Consequently, the surgery. Based on their results, the authors illustrate a several factors have switched the inpatient surgery to an technique with a high degree of success and low risk pro- outpatient setting, given the fact that early discharges can file, with an awake craniotomy failure rate of 0.5%, early decrease well-defined risks derived from an in-hospital (at discharge) postoperative neurological deficit of 9%, and stay and can have a positive impact on the patient’s psy- late (more than 3 months after the surgery) neurological 12,27,49,52 29 chosocial sphere. Although same-day neurosurgery deficit rate of 3%. Specifically in neuro-oncology, such has proven to be a safe method, with potential benefits for advances have yielded far-reaching consequences by im- the patient and the health care system globally, its expan- proving extent of resection, increasing overall survival in sion has been faster in other surgical specialties.19,22,43 low-grade and high-grade gliomas, and decreasing post- 5,20,21,29,46–48,50,51 Physicians who perform intracranial neurosurgery have operative morbidity. Besides its application been reluctant to apply same-day surgery protocols, main- in guiding surgery in eloquent areas, awake craniotomy ly because of the perceived risk of further deterioration constitutes an invaluable neurosurgical tool by reducing when the patient is discharged shortly after an intracra- anesthesia risks as well as delivering a direct impact on 53 nial procedure. Be that as it may, several large-scale series resource optimization. analyzing complications after both biopsy and craniotomy As a result of these potential implications, outpatient procedures have suitably addressed the time frame after brain tumor surgery was initially introduced by Bern- 7 which the physician can consider it safe to discharge a pa- stein in 1996, when the senior author started applying this tient from the hospital.10,33,53 technique in 46 patients prospectively selected to undergo In their retrospective study performed in 1994 to ana- awake craniotomies to evaluate the feasibility of a new lyze postsurgical complications after CT-guided stereo- same-day brain surgery protocol. The results obtained, tactic biopsy in 300 patients, Bernstein and Parrent report- with an 89% successful discharge rate, paved the way for ed that only 3 of 300 patients developed a neurologically the introduction of this technique. relevant intracranial hemorrhage more than 4 hours after the procedure.9 In another study analyzing the incidence Impact of Awake Craniotomy on a Patient’s Survival and and timing of complications after intracranial surgery, Neurological Morbidity Taylor et al. reported clinical deterioration as a conse- The scientific evidence currently available supports the quence of postsurgical hematoma within 6 hours of the tenet that maximal safe removal of hemispheric
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