BRAIN TUMOR SURGERY PROCEDURES, PREPARATION, AND SURGERY PROCESS

Diagnosis of brain tumor is a difficult period for every patient and his/her relatives in terms of their emotions. In this period, patients want to get as much information as possible about their diseases, and even want to make a decision after getting such information confirmed by several neurosurgeons. In some cases, patients who have decided to have surgery remain undecided about choosing a physician. In this indecision period, support of the patient’s family is very important.

If your diagnosis is clear, I will give you detailed information, in the light of your medical history, examination results and imaging findings. Information to be provided includes the location of the tumor, surgical difficulty, possibility of benign or malignant tumor (as a preliminary prediction in the light of imaging procedures), planned surgical method, duration of surgery, postoperative intensive care period, total hospital stay, impact rate of surgery on the quality of life, surgical and vital risks, and financial dimension of surgery.

After you have decided on your surgery, we will prepare the tests including the necessary preoperative laboratory and imaging procedures, and then we will send you to the anesthesiology department to get approval. After the approval, the final preoperative stage is the determination of the surgery day. If the patient has no urgent clinical condition, systemic disease or general condition disorder that needs to be treated first, it is generally adequate to hospitalize the patient in the morning of the day of surgery.

Treatment options are determined based on the type and location of the tumor, and the analysis of the treatment results in the literature. However, the options generally include surgical treatment, radiotherapy (radiation therapy) and chemotherapy. In most of brain tumors, surgical intervention is the prioritized treatment option. However, surgical access may be impossible in the treatment of some tumors localized in the brain stem. In such a case, the option may be radiotherapy (radiation therapy).

How is a Craniotomy Performed in the Treatment of Brain Tumors?

This operation is done under general anesthesia. First, the surgical site in the scalp is shaved. A skull clamp with pins is applied to the patient for positioning and immobilizing the head. The surgical site is then cleaned with antiseptic solution. Afterwards, the edges of the surgical site are covered with sterile surgical drapes. After the preparation of the other surgical equipment is completed, craniotomy is started. An incision is made in the scalp in accordance with the pre-drawn borders. The skin flap and the subcutaneous tissues (galea and periosteum) are peeled back. Burr holes are drilled in the skull with a special device, and then a bone flap in the predetermined size is removed. The bone flap is stored for closing the surgical site at the end of the operation. After removal of the bone flap, the exposed tissue is a layer of membrane surrounding the brain. Once this membrane is peeled back properly, the brain tissue is accessed. If the tumor is deeply seated, a computer-assisted system called navigation can be used to ensure minimum damage to the brain tissue. The procedure is performed under a microscope. The area of the brain tissue other than the incision site is protected with soft cotton, and then a small incision is made in the planned location. The least risky passageway, likely to cause minimum damage to the brain tissue, is selected depending on the location of the tumor, and then the brain tissue is accessed. After this point, the tumor is removed with the appropriate surgical technique. In the tumor removal process, the state-of-the-art technology is used in terms of the condition of the operating room and surgical instruments. After the removal of the tumor tissue, the next is another important stage that requires very careful bleeding control. After the completion of this stage, the membrane called dura mater is closed up, and then the bone flap removed at the beginning of the operation is fixed in its place in the skull. Afterwards, the operation is terminated by closing up the periost covering the bone, the galea, subcutaneous tissue and skin. Some tumors may destroy the cerebral cortex and bone tissue. In such cases, the cerebral cortex can be repaired by using bio-compatible synthetic tissues after the removal of the bone tissue. In surgical treatment of posterior fossa tumors, the bone tissue in the surgical site is sometimes removed after divided in smaller parts, and the site is then repaired by using the abovementioned synthetic tissues. The surgical site is also cosmetically corrected.

Things You Wonder About the Postoperative Period of Brain Tumor Surgery

After surgery, you will be admitted to the post-anesthesia care unit (PACU) and then to the intensive care unit. Intensive care, the process that patients are curious about and may be afraid of the most, is experienced under more comfortable and sufferable conditions by means of the widespread use of technological facilities and the support of our well-trained intensive care personnel.

When the patient admitted to the intensive care unit comes out of anesthesia, he/she naturally tries to understand his/her current condition. He/she is in the position of a patient who has an IV drip attached to his/her arm, cables attached to his/her chest for monitoring the cardiac rhythm, a surgical site covered with dressing materials in his/her head, and another cable attached to one of his/her fingers for measuring the blood and oxygen condition. Since the patient’s consciousness should be controlled at frequent intervals, he/she will be woken up frequently on the first night. Therefore, the patient will spend the first night partly sleepless. The patient should also be calm and avoid excessive movements when trying to figure out his/her condition. It is a prerequisite to give such clear information to our patients before surgery and enable them to experience the postoperative intensive care period more comfortably. After spending the first night in the intensive care unit, the conscious patient is started on a diet suitable for his/her condition. A follow-up CT scan is performed on the first postoperative day, and then the patient is examined for the last time before he/she is taken to his/her room. Patients are usually taken to their rooms after the second postoperative day. Patients are discharged after they stay in their rooms for a period of 3 to 5 days on average. Sutures of the discharged patients are removed on the 8th to 10th day. Once discharged, patients need to use some medications at home. Therefore, a written note about how to use the medications is given to patients for ensuring them to use their medications regularly.

Complications After Brain Tumor Surgery

Headache, weakness and fatigue are the most common symptoms experienced by patients after they come out of anesthesia. Headache may last several days. Weakness period of patients may last longer.

One of the most important steps during termination of brain tumor surgeries is to make sure that there is definitely no bleeding in the brain tissue. However, patients may need to be re-operated under emergency conditions due postoperative bleeding despite all the care and cautiousness.

Infection may develop in the incision site, in the bone tissue that constitutes the skull, or in the brain tissue. In such a case, medical treatment and/or surgical treatment may become necessary.

Another problem encountered is brain edema. In its simplest definition, edema is an increase in the water content of the cells in the brain tissue. Brain edema problem can be resolved with steroid containing medications (cortisone) and/or a group of medications intended to reduce water content of brain cells. If surgical treatment is necessary, the intracranial pressure is reduced by draining the excess cerebrospinal fluid into an eternal bag through a tube placed in the cerebrospinal fluid sac, or into the abdominal cavity through a catheter placed there.

Patients may sometimes suffer from loss of strength in their arms and legs, problems in thinking, sight, speech, as well as consideration and judgement of events, depending on the location or size of the tumoral formation, or surgical procedures and methods. Risks related to these problems can be partially predicted through preoperative imaging methods. Most of these problems decrease or disappear in the course of time after surgery. However, some disorders can be permanent.

Patients may have seizures (epileptic attacks) before surgery due to the effect of the tumor, and also after surgery due to the effect caused by the surgical operation. In such cases, the patient is started on one of the medications used for epilepsy patients. The patient is ensured to use the medication regularly because such medications can be effective only when they reach a certain level in the blood. This level should be checked after 20-day use of the medication, and then a dose adjustment should be done if necessary. In addition, many antiepileptic medications potentially have negative effects on the liver and blood values. Therefore, patients should be checked with complete blood count and liver function tests once every 3 months. In addition, patients having seizures should be particularly careful to avoid endangering their own lives as well as that of others in certain circumstances in their daily lives (by driving or swimming alone in the sea etc.).

Radiotherapy and Chemotherapy for Brain Tumors

Radiotherapy (radiation therapy) is another treatment method commonly used in neurosurgery practices. Radiotherapy can be performed before or after surgery. In radiotherapy, therapeutic radiation beams are applied to the excision site of the tumor in the brain; or to the area where a part of the tumor has been removed but the rest of it is still in the brain tissue; and also to the surrounding brain tissue in the postoperative period. Sometimes radiotherapy can also be performed without surgery, in cases where the tumor is located in a place that may cause serious complications in consequence of a surgical treatment, or where the patient’s general condition is not suitable for surgery.

Redness and tenderness on the skin, hair loss, nausea, and vomiting may be seen after radiotherapy. Moreover, edema of brain tissue (an increase in the water content of the brain tissue) and a consequent increase in the intracranial pressure can be seen. It is decided to apply radiotherapy to children only when it is quite necessary. It is because radiotherapy has negative effects on growth and development, and deteriorates the cognitive functions of the brain (thinking, judgment, decision making, and intellectual functions) in children. Therefore, consultation between clinics (neurosurgery, radiation oncology, medical oncology, pediatric diseases) may be needed more frequently when carrying out the treatment plan after pediatric brain tumor surgery.

Chemotherapy is a treatment method used to kill the cancer cells in the brain tissue or cancer cells that have remained after a surgical operation. The most important factor determining its use after surgery is the test results that will be taken from the pathology department. Sometimes it is applied especially to children to avoid the negative effects of radiotherapy and gain time for children until they reach the period when they will be least affected by radiotherapy. Chemotherapy is administered in certain intermittent periods. This method is intended for ensuring patients to be less affected by the negative effects of drugs. The department that plans the chemotherapy process is medical oncology clinics. There are also extended-release chemotherapy agents placed in the cavity resulted from the removal of the tumor in the brain tissue. After these are placed, the surgical site is closed up in accordance with the standard method. The medication is slowly released in the body, and kills the cancer cells.

Life After Brain Tumor Surgery

When the surgical operation of a patient diagnosed with brain tumor is successfully completed and the patient is discharged from the hospital, a totally different life will start for our patient and his/her family. Pathological diagnosis of the patient is the most important factor among many factors regarding how this life style will be and whether an additional treatment will be necessary. Pathologic results can sometimes be obtained rapidly by means of an emergency pathology study performed in surgical operations (frozen tissue biopsy), but a pathological diagnosis is usually achieved 5 to 8 days after special dyeing processes carried out in laboratories.

Other factors affecting the postoperative life include the patient’s age, preoperative clinical condition, whether the tumor can be removed, whether an additional treatment is necessary, and adequacy of the post-operative cognitive functions. All of these should be evaluated jointly by the physician, patient and his/her relatives and psychiatric support should be received if necessary. The physician should be not only a surgeon carrying out the surgical operation, but also a person who supports the patient in his/her social life.

Postoperative stroke, severe intellectual dysfunctions, and confinement to bed may be seen. Although these are always a possibility after surgery, their overall incidence rate is low. Postoperative mortality rate is very low. If there is a possibility of serious sequelae that can be seen before surgery, this should be clearly discussed with the patient and his/her family.