The following is an edited transcript of an MDAdvantage podcast with Steve Adubato, PhD, Jean Anderson Eloy, MD and James K. Liu, MD, recorded on January 25, 2023. Dr. Eloy is Chair of Otolaryngology – Head and Neck Surgery at Cooperman Barnabas Medical Center and Vice Chair and Distinguished Professor at Rutgers New Jersey Medical School. Dr. James K. Liu is the Director of Cerebrovascular, Skull Base and Pituitary Surgery at Rutgers Neurological Institute of New Jersey and Cooperman Barnabas Medical Center, and Professor of Neurological Surgery at Rutgers New Jersey Medical School. In this interview, the two surgeons describe their team approach to a state-of-the-art Endoscopic Skull Base Surgery Program that uses an endonasal technique to remove brain tumors, previously performed with a craniotomy. They discuss the benefits of this advancement, as well as their techniques in communicating complicated surgeries to patients and their families.
ADUBATO: I am pleased to speak with two surgeons who do very important work together. Dr. Liu, what is your area of expertise, and how did you come to work with Dr. Eloy?
LIU: I am a neurosurgeon by trade, and I specialize in the surgical treatment of various neurological diseases. The areas I specialize in are primarily brain tumors, pituitary tumors and skull base tumors, such as acoustic neuromas and meningiomas, and vascular diseases such as aneurysms, arteriovenous malformations (AVMs), moyamoya and stroke. I work together with Dr. Eloy in a team approach that combines my field with his, called endoscopic skull base surgery.
ADUBATO: Dr. Eloy, please elaborate on endoscopic skull base surgery. How does your focus as a physician differ from Dr. Liu’s?
ELOY: Our training is different in that I am an otolaryngologist, and I did a fellowship in rhinology, sinus, and endoscopic skull base surgery. Dr. Liu is a neurosurgeon who specializes in skull base surgery. Our two fields come together to meet in the middle of the skull. Instead of using the traditional method of craniotomy (making an incision on the head and opening the skull) to remove a tumor in that part of the brain, Dr. Liu and I have combined our respective areas of expertise to be able to remove skull base and pituitary tumors through the nose and nostrils in a way that is less invasive for patients and can provide a better outcome (see Figure 1).
ADUBATO: Dr. Liu, can you tell us about some of the recent advancements in neurosurgery?
LIU: Neurosurgery is actually one of the newest medical specialties, and it’s one of the fastest growing in terms of innovations and technology. It is technologically driven, so we’re very involved with developing new devices as well as new drug therapies to target various brain tumors. We also can implant stimulators to help alter neurological pathways, such as in Parkinson’s disease, for tremor control. And we can now reverse the effects of a stroke through interventional treatments with a puncture in the wrist. It is a rapidly forward-moving field.
ADUBATO: What other conditions are you and your colleagues able to help treat with these incredible advances in neurosurgery?
LIU: As neurosurgeons, we treat a wide variety of neurological disorders. The broad category includes conditions like movement disorders (like Parkinson’s disease), brain tumors, epilepsy, stroke, and vascular disease and also brain aneurysms. As neurosurgeons, we also deal with a lot of spine disease as well, such as degenerative spine disease or tumors in the spine or spinal cord.
“Neurosurgery is actually one of the newest medical specialties, and it’s one of the fastest growing in terms of innovations and technology.”
ADUBATO: Dr. Eloy, when it comes to endoscopic skull base surgery, explain why that particular technique is so important and impactful in terms of recovery and prognosis for patients who are being treated for brain tumors.
ELOY: If you picture the skull base being at the center of the skull/head, it is located in the middle. So, we’re going into the deepest place in somebody’s head to remove a tumor within the brain. The way we used to do things is to make a big cut over the head and retract the brain to get to the pathology. Physicians would have to go through some brain tissue or would have to move the brain out of the way by putting pressure on it to get to the middle of the skull. What we’ve been able to do with our new techniques is use the natural orifices. We can now go through the nose, where there is an air cavity, and make sure not to disturb anything important on our way in. We can get to our target very quickly and easily without impacting other structures. After the surgery, the patient may have had a big brain tumor removed, but is able to go home the next day or the day after, as opposed to being in the hospital for about a week with the traditional surgical method.
ADUBATO: Dr. Liu, this is a complicated surgical procedure. How do you go about explaining it to the patient?
LIU: I tell patients that I think of this like a two-story house: Dr. Eloy’s area, his space, if you will, is the first floor, which is the nasal cavity. The brain lives on the second floor. So, the ceiling of the first floor, which is also the floor of the second floor, is that barrier where the brain sits at the base of the skull. We have a variety of conditions, such as pituitary tumors, craniopharyngiomas, meningiomas, and some head and neck cancers, that can arise from that barrier between the first and second floor. Instead of the traditional method of taking off the roof of that house and entering the brain cavity to get to these tumors (through a craniotomy), we’re now going to go down on the first floor and open up the ceiling like a trapdoor and take out that tumor through the nose, instead of opening the skull. That in essence is endoscopic endonasal skull base surgery.
Figure 1. Endoscopic Endonasal Removal of Skull Base and Pituitary Tumors
ADUBATO: The ability of each of you to communicate in a way that a layperson like myself, or your patients or even clinicians who are not experts in this area, can understand is extraordinary. Dr. Eloy, how important is it for you as a physician leader to be able to explain and communicate to people what you are doing, why you’re doing it, and what it means to that patient and their family.
ELOY: We are talking in terms of informed consent, which is driven by the guidelines and recommendations of the American Medical Association, the U.S. Department of Health and Human Services, and the National Institutes of Health. To get consent from someone, they have to understand the procedure. In fact, it is recommended that a consent form is developed between the fourth and sixth grade reading level. It is not just the consent that you have to get, but you also have to be able to explain to the patient what you’re doing to them in relatively simple terms so they can comprehend the potential bad outcomes. I want the patient’s family to be involved wherever possible as well.
ADUBATO: Dr. Liu, do you use any graphics to assist you with the patient communications?
LIU: Yes. For example, I can show an MRI picture of a brain tumor (see Figure 2). In this case, it is a scan of a tumor called a meningioma in the base of the skull, and it’s compressing the brainstem and involving some of the nerves that exit from that area. The tumor can cause weakness of the arms and legs, possible paralysis, and facial numbness. The graphic illustration next the MRI (see Figure 2) is one of the surgical approaches that we can take to the skull base to remove a complex tumor like this, and you can see there are a number of very important critical structures that we’re working around, namely nerves, vessels and brain tissue.
Figure 2. Skull Base Surgery
ADUBATO: Dr. Liu, what are some of the biggest challenges you face as a neurosurgeon?
LIU: We, as surgeons, have to walk that fine line between getting the tumor out and delivering the patient safely out of harm’s way. I like to say that sometimes we have to make an intraoperative judgment, what I call a surgical audible or a gametime decision. Sometimes we have to balance that fine line of getting all of the tumor out or nearly all of it and still preserving these nerves. For example, when we remove tumors like acoustic neuromas (see Figure 3), we sometimes have to make a gametime decision to leave a residue or remnant of tumor that can be stuck to critical nerves and vessels to preserve facial nerve function and avoid complications of neurological injury and facial paralysis. We always want to make sure our patients come out of surgery with the best neurological function. The tumors often compress the optic nerves and brainstem that can result in loss of vision, motor weakness and paralysis in our patients. And when we remove these tumors, we can potentially reverse these symptoms. In what other profession can you say that today I helped the blind to see and the lame to walk. I feel very blessed and grateful to be doing this, and thankful for our patients who entrust their lives to us. I can’t imagine doing anything else.
Figure 3. Removal of Acoustic Neuroma Tumors: Walking the Line Between Maximizing Tumor Removal and Preserving the Facial Nerve