Performing head surgery on a conscious patient (awake craniotomy) might seem pure cinema to the uninitiated. But practitioners like Legaspi now speak from experience about its practical advantages after notching up some successful live operations done by himself and three other surgeons from St. Luke's Medical Center (SLMC), The Medical City, and the University of the Philippines-Philippine General Hospital (UP-PGH). Legaspi has personally done two such operations at The Medical City and 10 at UP-PGH.

    For now, the local operations mostly involve the eloquent parts of the brain, or those areas having to do with speech and understanding. Here, the techie buzz term "real-time interactivity" takes on a whole new meaning in neurosurgery.

    The surgeon is actually guided by the patient's spontaneous response on the operating table while doing his delicate job, instead of just relying on anatomical stock knowledge. In situations where there is a trade-off, for example, between the full excision of a troublesome tumor and possible injury to the patient's functions, the surgeon is able to make a more informed decision.

    The awake brain is said to be more relaxed too, making the surgeon's job easier.

Making a comeback

    The local revival of a technique that's been around since the 1920s or ever since practitioners have had to grapple with the lethal unpredictability of ether anesthesia was a long time coming. Dr. Harvey Cushing, the acknowledged father of modern neurosurgery, had his share of tough reckoning in this regard, leading him to find a way to operate on his patients using only local anesthesia.

    A Filipino surgeon in the late 1950s, Dr. Victor Reyes, was said to be the first to do it here after his epilepsy surgery training abroad. Although the practice is already common in the West, it took decades-as late as last year only in fact-before Reyes's later-generation colleagues, starting with SLMC's Dr. Vladimir Hufana, took up this surgical challenge again.

    Most practitioners who have gotten around to the idea of doing it hesitate out of inexperience. "The idea of someone being awake and the absence of analgesia because there's no anesthesia didn't jive too well with most surgeons," Legaspi speculates. "The first reaction is kung gising ang pasyente, paano yung pain?"

    He himself deems his foray into awake craniotomy as a leap of faith. After seeing the procedure done abroad on one of his patients, he finally got up the resolve to try it after a local talk from Toronto Western Hospital's Dr. Mark Bernstein who has 700 live cases under his belt. He also got a cue from the successes of local colleagues like Hufana and UP-PGH's Dr. Yvet Sih.

    Another big realization for him was that he and other qualified local neurosurgeons already have the toolbox to make it happen, although they may not have access at the moment to certain technical gadgets like advanced stimulators to mark off areas in the brain.

    He says it boils down to the application of basic neurosurgical principles. What's more critical is having the support of a good anesthesiologist.

A feat of anesthesiology

    Awake craniotomy is said to be less a feat of surgical derring-do than an anesthesiological achievement. "It is important to keep the patient stable in terms of vital signs, neurologic- and behavior-wise and it's the anesthesiologist on the other side of the drapes that does a big part of keeping the patient awake, 'behaved', cooperative, and comfortable," says Legaspi.

    There being more prerequisites to doing such operations than sheer medical necessity, anesthesiologist Geraldine Jose says not all patients are candidates for it. "They have to be psychologically prepared first. It's very important that the patient understands what he will go through. And obviously his concerns have to be addressed on an individual basis because each patient is different, so we really spend time talking to them."

    This technique is also advised only for surgeries of up to a three-hour duration for reasons of patient comfort. The patient has to maintain a single position all throughout the operation, one that is most comfortable to him and would give a good angle for the surgeon to work on.

    Filipino patients have shown themselves to be ready for it, says Legaspi. "We've noticed that whether the patient is a tricycle driver or a bank executive, they all have the same behavior during surgery. No one panicked and wanted out in the middle of it. In the cases we've had so far, yung mga fears na baka umubo ang patient, lumuwa ang brain, or gumalaw, none of that happened. I guess it's really how you brief them."

    During crunch time, the anesthesiologist's technical prowess sets the stage for the main phenomenon of having a patient cut up in the head to within an inch of his life, yet still in full control of his faculties.

    The patient needs to be awake only during the critical part when his functions have to be tested. This means that the anesthesiologist will have to put the patient to sleep during the opening and closing of the skull and the wound, and ensure the right amount of sedation during the patient's conscious period in between.

    Anesthetic emergencies, big and small, also have to be covered. Intravenous anesthetics are on hand for analgesia, spontaneous bouts of anxiety, and other such little crises. And when things go totally awry, she has to be ready to go back to general anesthesia.

    It's a high-wire act in anesthesiology. That's why more than the surgeon, it's the attending anesthesiologist who might need the extra training. Having worked with Bernstein in Canada, Jose is probably the only subspecialist in awake-craniotomy anesthesiology in the country.

    In terms of equipment, she says even a government hospital like UP-PGH where she practices already has the proper equipment for the demands of her job. To date, there are actually more live operations done at UP-PGH than in the two private hospitals that had likewise hosted it in their ORs.

    Economics might have a part to play here. Based on their observations, Legaspi and Jose think patient recovery period is reduced by half in live operations because of the lesser burden from the debilitating effect of general anesthesia. That's good news for hospitals like UP-PGH where so many patients vie for the same hospital bed and are generally less financially capable anyway to prolong their stay.

    In Canada, Jose says an awake-craniotomy patient can be discharged in less than 24 hours compared with the five to six days of hospital stay for fully anesthesized surgeries. It is important, however, that the patient undergoes computed tomography (CT) before discharge and can be easily be brought back to the hospital when needed.

    This practical advantage probes the possibility of offering awake craniotomy even for noneloquent brain operations. Some surgeons abroad are already using it as a regular technique for outpatient tumor surgeries.

    Legaspi says that with the more than 10 live operations he's done, he's still learning a lot. "The lessons we've picked up have made the patients' experience a lot more comfortable," he adds. M

 

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