Surgery & Radiation: Q&A
How to find a qualified Surgeon
Many readers either have had or will have surgery to remove a pituitary tumor. This operation is called a Transsphenoidal Adenectomy, so named because it involves removing the tumor (adenoma) by going through (trans) the sphenoid sinus (sphenoidal).
Despite the superior safety characteristics of Transsphenoidal surgery, there are some risks. In addition, any time one undergoes surgery, there are some risks. Patients and their loved ones rightly worry about the outcome of the surgery. And, as one might expect, the experience of the surgeon makes a big difference in outcomes.
In 1997, a team led by Ivan Ciric, M.D., at Northwestern University’s Evanston Hospital, published the results of a survey of nearly 1,000 neurosurgeons practicing in the U.S. This article can be found on the Web at www.c3.hu/~mavideg/ns/ciric2-97.html. In their report, first published in the journal Neurosurgery, Ciric and company discuss their findings based on the responses of 958 neurosurgeons who had performed transsphenoidal surgeries on pituitary tumors.
The authors concluded, “Transsphenoidal surgery seems to be a reasonably safe procedure, with a mortality rate of less than 1%.”
On the other hand, the article indicates that a significant number of complications do occur with less-experienced surgeons. Surgeons who have performed 200 and even 500 transsphenoidal operations show significant improvement in successful operations. As you can see from the survey by Ciric and company, a surgeon’s experience says a lot about the outcome of a transsphenoidal operation.
The article is a great source of information, but the question for most patients is “how do I make use of all this?” For this article, we asked three members of the PDES Medical Advisory Board to help understand what sort of questions to ask a neurosurgeon to help gauge his/her experience.
Getting off to a good start
To begin, many patients will ask, “How many of these surgeries have you performed?” It is possible that some physicians do not immediately recall the exact number of pituitary surgeries they have performed. Questions worded this way usually only leave room for two types of responses – either a flat number or an evasion.
It may be more helpful to ask how many times a month a surgeon performs transsphenoidals, and how long he or she has been in practice. After that, a patient might ask if that surgeon has performed more of these procedures over the past few years than earlier in his/her career.
Given that approach, patients might discover that Dr. Jones, a surgeon with 10 years’ experience, typically performs one transsphenoidal a month. You can surmise that Dr. Jones has performed about 120 transsphenoidals.
This discussion points out one unavoidable conclusion: you have to do your homework. Though it is a stressful time for gathering information and decision-making we hope this interview with three qualified surgeons will help you feel more confident in the process.
Q. What do you think are the three most important questions a patient can ask a neurosurgeon?
How long has the surgeon been in practice? How many transsphenoidal operations does the surgeon perform each year? Does the surgeon work closely with an endocrinologist?
A patient can determine a physician’s experience by asking how many cases the surgeon would see in a year and how many operations he/she has performed. I would think that a surgeons doing about 10 cases/year for a few years would have sufficient experience to handle most tumors but, in determining experience regarding patients with Cushing’s disease, the number ought to be higher and an experienced endocrinologist should be involved as well.
Patients should ask the neurosurgeon how many of these operations he/she has performed and the outcome rates and complication rates.
Q. What sort of preparation should a patient undertake before the first appointment with a neurosurgeon?
The patient needs to have in hand all images, such as MRI scans (not just the reports), and also copies of all endocrine blood tests. They should ask the referring doctor exactly what has been diagnosed and why they are being referred to a neurosurgeon.
A patient should have all hormonal results (especially prolactin) or the reports from an endocrinologist, and, if visual problems are occurred, the results of an ophthalmologist consultation. Additionally, an MRI of the pituitary region (i.e., sella) must be available.
It is of utmost importance that the patient sees an endocrinologist who has taken care of patients with pituitary tumors before an appointment with a neurosurgeon. The patient may need vital hormone replacements before surgery and if the tumor is a prolactin-producing tumor, surgery may not be necessary.
Q. Many in the healthcare industry feel that the experience of the institution is as important as that of the surgeon in predicting outcomes. Do you agree?
The experience of the surgeon is the most important issue. However, the quality of the institution is important for postoperative care and also tells the person something about the surgeons who would be hired to work there.
If we are discussing surgical outcomes, the experience of the surgeon is paramount. “The experience of the institution” is a nebulous concept and is more often promoted by inexperienced physicians. The successful management of patients with pituitary tumors boils down to the expertise of the primary care doctor (realization of the clinical problem), endocrinologist (determination of the hormonal details) and the surgeon (when a surgeon is necessary which is not the case in many cases).
If a person is to have pituitary surgery, the most important issue is the experience and expertise of the neurosurgeon. The “institution” has nothing to do with the outcome, but it is important to have a close collaboration between the neurosurgeon and the endocrinologist for optimal perioperative and postoperative management.
Q. In some instances, a patient has no choice but to go with a surgeon with very limited experience. Do you feel that more experienced surgeons would be willing to consult with those who are less experienced prior to an operation to pass along some helpful advice?
It is not realistic to pass on advice for a single operation. Experienced surgeons should be involved in teaching courses at national or regional meetings for less experienced surgeons. It is certainly advisable for the less experienced surgeon to show the films to another surgeon to ask his or her opinion about an approach or the advisability of surgery, but not for advice on how to do the surgery. I think every surgeon should be very open to the idea of a second opinion for the patient. The less-experienced surgeon may want to go watch the expert do several cases.
Although this sounds good in concept, the verbal consultation is not likely to change the outcome very much. Surgeons who are less experienced can always consult with more experienced surgeons, but to give advice over the phone is less than optimal. I doubt that, in practice, this process would work for long.
This is not a practical question because the “experienced” surgeons can’t be there to give advice. Advice on the phone is not practical and is not good medical practice. Surgery is taught in the operating room with the experienced surgeon directing the trainee.