by Pat Kramer and Alicia Di Rado
Some 5,000 years ago, ancient Egyptians were the first to operate through the nasal passages. Their surgical device: a special hook that, when inserted through a nostril, allowed morticians to remove brain matter for the mummification process.
Fortunately, surgery has advanced over the millennia.
Today, neurosurgeons such as Behnam Badie, M.D., director of the Brain Tumor Program at City of Hope, have perfected highly sophisticated techniques to operate on the brain through the nose, using minimally invasive strategies to remove pituitary tumors as gently as possible.
Badie has unique expertise in the strategy, dubbed the endonasal transsphenoidal approach. An authority on the technique, he has published a number of articles on the topic, including a chapter in the “Neurosurgical Operative Atlas — Neuro-Oncology,” an American Association of Neurological Surgeons textbook he recently edited.
As Badie explains, tumors and cysts may arise in the pituitary gland or in the tissue surrounding it, called the sellar region. The area lies behind the nose and sinus. Although only 10 to 15 percent of all brain tumors are pituitary tumors, and most of these are benign, they can cause troublesome hormonal and neurological symptoms that can be relieved through surgery.
But few have the surgical mastery and equipment to operate using the latest, most precise endonasal methods, which offer advantages over earlier approaches.
“For years, surgeons were using what we call the sublabial-transseptal approach, where incisions are made through the upper lip and the septum of the nose — the cartilage — to access the brain,” said Badie, who has performed more than 200 pituitary procedures. “This offered less facial scarring than earlier techniques, but patients still experienced post-surgical trauma. And patients could be left with septal perforation and permanent damage to the sinuses.”
The newer endonasal approach, developed within the last decade, unites the visual precision of a slim, tiny camera, called an endoscope, with the power of a navigation system, magnetic resonance imaging and highly specialized microscopes. The equipment in City of Hope’s operating room magnifies the tight surgical field while the StealthStation AXIEM electromagnetic navigation system guides surgeons to their targets, much like a global positioning system, or GPS, in a car.
The system provides stereotaxy — the ability to pinpoint important structures three-dimensionally in the brain — without requiring a patient’s head to be held in place within a rigid frame.
“The combination of the endoscope, operating microscope and frameless stereotaxy has improved the endonasal transsphenoidal procedure by freeing the surgeon’s hands, while also providing stereoscopic visualization,” Badie said. “Using these devices reduces operating time and provides easier control of bleeding. As a result, my patients have not experienced any cosmetic complications or nasal perforations, and most patients are discharged home within 48 hours.”
Research indicates that the endonasal approach is as effective as the sublabial-transseptal technique in removing pituitary tumors, but patients experience less pain through the endonasal approach.
Besides his successful procedures at City of Hope, Badie also has contributed to the surgery’s effectiveness worldwide. He invented two surgical instruments used in the transsphenoidal procedure: the Badie Suction Bipolar Forceps, which a surgeon may use to both grasp tissue and clean the surgical area, and the Badie Sellacon Plate, a reabsorbable plate that is used to reconstruct the sella after surgery.
More information about the pituitary surgery technique is available on the program’s Web site, www.cityofhope.org/braintumor