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Brain Surgery Made Simple
New Less-lnvasive Procedures Reduce Pain, Recovery Time; Sending in the Tiny Robots
by Peter Landers, Wall Street Journal

Looking at Doublas Baptist, you'd be hard-pressed to figure out he had brain surgery seven months ago.

Mr. Baptist's doctor opened up a hole in his eyebrow, plucked out a tumor bigger than a golf ball, then sewed him up again. Today, his eyebrow hairs cover the scar. "I'll say I had brain surgery and people say, 'Are you crazy?'" says Mr. Baptist, 49 years old, a bridge-painting supervisor for the city of New York.

This is the latest frontier in "minimally invasive" surgery. Over the past 15 years, doctors have tried to reduce the pain, scarring and long recovery periods traditionally associated with surgery in general. Instead of cutting a patient's abdomen wide open to remove a gall bladder or kidney, doctors do the surgery through small keyhole incisions. Now, thanks to better instruments, doctors can try similar operations on the most delicate organ of all: the brain.

"We used to have to shave off half the head," says Mr. Baptist's doctor, John Mangiardi of New York's Lenox Hill Hospital. "We don't do that anymore."

The new approaches are good news for many of the roughly 186,000 Americans who are diagnosed annually with brain tumors. Since the cause is still unknown (though cellphones don't seem to be a risk factor), the only treatment has been to attack them after they appear. The usual way of getting at a hrain tumor is to saw open a section of the skull, but less invasive approaches mean patients can go home faster and look better.

The new techniques mainly help people with less serious tumors, such as those that grow in the membrane surrounding the brain. Symptoms at first are fairly mild, such as dizziness or hearing loss. Patients usually have time to explore their options.

The term "minimally invasive" covers a wide variety of brain-surgery procedures. Some doctors insert an endoscope - a tiny camera and light - through the nose, or via an incision tucked behind the ears, to view the tumor area. In one particularly new and experimental Japanese technique, tiny tumor-excising tools like lasers and forceps are then inserted and guided with a joystick by a doctor watching on a TV monitor.

Yet another approach, which obviates the need for cutting entirely, is radiomgery. Two companies are producing multimillion-dollar devices that zap hrain tumors with precisely focused beams of radiation.

Some of the new techniques have their critics. For instance, radiation could cause long-term damage and doesn't completely eliminate tumors. In addition, it takes a long time to build up data on experimental techniques, because most patients would rather go with the tried-and-true. Dr. Mangiardi in New York says he originated his eyebrow surgery in 1993 on a Venezuelan woman who was petrified at the prospect of suffering an unsightly scar; that operation was a success. Nine years later, he is close to operating on his 100th patient, and only now is he ready to publish an article in a scientific journal with enough data, he says, to show that his method works.

The decades-old approach to brain surgery is still widely used also because doctors need many years to master the new skills and then teach them to other doctors. "You can't just say, 'Give me an endoscope, I'm gonna do it,'" says Hrayr Shahinian, head of the Skull Base Institute at Cedars-Sinai Medical Center. "It took me 10 years. I must have killed 200 pigs," he says. (Brain surgeons sometimes practice on pigs since their brains are roughly human-sized.)

The bad news is that many brain-tumor victims still won't benefit much from minimally invasive surgery - or, in fact any other kind of surgery. These patients have tumors that spread tentacles deep into the brain and multiply rapidly. "No one survives this disease. It's a death sentence," says Eric Holland of the Memorial Sloan-Kettering Cancer Center in New York.

Minimally invasive approaches to brain surgery have taken longer to develop than other kinds of surgery because of the thin margin for error. In the brain, anything less than perfect precision risks damaging the gray matter and leaving patients blind, deaf, mute or worse.

All this means patients need to do a lot of research on their own until they find a surgeon and procedure that they feel comfortable with. Dave Galbraith, a 65-year-old construction manager in Duncanville, Texas, had a tumor near the front of his brain, and ended up visiting four different neurosurgeons until he found Dr. Shaninian in Los Angeles, who said he could remove the tumor without damaging Mr. Galbraith's sense of taste and smell. Mr. Galbraith brought that information back to one of his earlier doctors, who scoffed: "That's Hollywood. They're just saying that to take your money." The surgery ended up being successful.

Nowadays, MRI and CT scans give surgeons a good map of where a tumor is. During surgery, various computer techniques for creating three-dimensional live images can help surgeons avoid damaging the brain.

Japanese researchers have come up with an experimental device that shows the future of the technology. The NeuRobot is a probe one centimeter in diameter that contains a stereoscopic endoscope (giving surgeons a three-dimensional view of the inside of the brain) plus three robot arms that can be fitted with millimeter-sized lasers and other tumor-attacking tools. The NeuRobot was first used on a human patient in late August at the Shinshu University School of Medicine in Matsumoto, Japan.

"This is the first ease of microsurgery assisted by robots," says Shigeaki Kobayashi, a Shinshu professor and president of the Japan Neurosurgical Society. Dr. Kobayashi, who developed the device with colleague Kazuhiro Hongo and researchers at Hitachi, predicts it will help doctors get at deeper tumors. Patients who now stay in the hospital for weeks could check out in two days, he adds.

Advocates of minimally invasive surgery say they can cut costs by as much as half by reducing hospital stays. Dr. Shaninian of the Skull Base Institute says traditional brain surgery costs $50,000 to $150,000, but the newer techniques can bring that down to between $30,000 and $60,000.

Insurance generally covers minimally invasive procedures, unless the hospital attempts to bill more than it would for conventional tumor-removal surgery. It's best to check coverage ahead of time.

Some doctors believe the best advances in surgery are those that eliminate the need to cut altogether. The Swedish-developed Gamma Knife and a newer rival, the CyberKnife, seek to zap tumors with precisely targeted radiation.

Anthony Boxer, a 56-year-old engineer in Union City, Calif., tried the radiation approach. Some doctors wanted to perform surgery, but Mr. Boxer, who once suffered a severe infection after sinus surgery, thought that was too dangerous. He ended up going for CyberKnife, which took up three mornings one week. It was so easy, he says, that he could have gone back to work as soon as it was done.

"It was anticlimactic," he says. "You expect the Frankenstein stuff, but there's none of that."