Threading their way past carotid arteries, optic nerves and other important structures, neurosurgeons Amin Kassam and Paul Gardner moved their surgical tools toward a site the size of a postage stamp at the base of the brain.

John Beale/Post-Gazette photos
Dr. Amin Kassam directs endonasal brain surgery being done through the patient's nose, in background, at UPMC Presbyterian.

To get deep within the 74-year-old patient's brain and remove the tumor growing there, the surgeons didn't open large holes in her skull, or remove any facial bones, or even push the brain around much. Rather, as is becoming increasingly common at the University of Pittsburgh Medical Center, they entered through her nose.

As Dr. Carl Snyderman manipulated an endoscope, a lighted viewing device inserted up one of the patient's nostrils, the surgeons could see the tumor, magnified so that it filled the screen of a monitor. Dr. Kassam guided his associate, Dr. Gardner, by drawing on the screen, much as John Madden might diagram a play on ABC's Monday Night Football.

The nose thus is becoming an important surgical window into the brain and through it UPMC surgeons are probing ever deeper as high-tech tools and improved techniques continue to extend their reach.

Guided by the endoscope and other imaging equipment, doctors use tools inserted through the nostrils to open small holes in the base of the skull and the membrane covering the brain. Tumors as large as baseballs are sucked away or removed in small pieces. The area is then covered by a replacement membrane.

Dr. Kassam has led the development of transnasal surgery at UPMC with Drs. Snyderman and Ricardo Carrau, both head and neck surgeons, and a neurosurgeon, Dr. Arlan Mintz.

The surgery, known as the expanded endonasal approach, cannot reach all brain tumors. Only about 30 percent form along the base of the skull, where they are most accessible through the nose, though Dr. Kassam said his team has been able to go beyond those areas in some cases.

The surgery is not without risks, including leakage of cerebrospinal fluid, which could lead to meningitis if left untreated. But Dr. Snyderman said that nearly all leaks have been repaired through subsequent endonasal surgery and that new techniques are being developed to improve control.

The surgery has spawned considerable debate. Some surgeons say it is too early to know whether the expanded endonasal approach is more effective than standard surgeries and that it is unclear how widely the technique can be applied.

	Dr. Paul Gardner follows Dr. Kassam's direction in removing the patient's tumor through the nose.

Dr. Kassam said his group's experience in more than 400 patients over the past seven years suggests that the surgery is at least as effective in selected cases as standard surgeries and is potentially less traumatic for patients.

Longer hospital stays are often more likely using conventional surgery, he said, particularly to remove tumors along the skull base.

Conventional surgeries to remove such tumors often require peeling back skin and muscle, cutting large holes in the skull or removing facial bones, and greater manipulation of the brain.

Jeffrey Braun, 34, has had experience with both types of surgery.

In 1999, he had a craniotomy -- a hole cut in his skull -- to remove a benign tumor behind his right eye. He lost about half the vision in that eye after the surgery and needed weeks to recover.

"It was quite an ordeal," the Charlotte, N.C., resident said.

But the tumor grew back, and Mr. Braun was already scheduled for another craniotomy when his father learned of Dr. Kassam's work.

When Mr. Braun told his local neurosurgeon that he planned to have the tumor removed through his nose, he said the doctor "literally laughed at me. He told me it was impossible."

But Mr. Braun had the operation at UPMC last month and was out of the hospital the next day. His vision has stabilized and may improve, Dr. Kassam said.

"They're miracle workers," Mr. Braun said of Dr. Kassam's team.

Tiffany Badams, 40, of Erie, also recovered quickly from her endonasal surgery.

She was pregnant with her fourth child in 2002 when she began having vision problems caused by a craniopharyngioma, a tumor that severely compressed her optic nerves.

Once the tumor was removed, her vision quickly improved. Though she had cerebrospinal fluid leakage from the surgery, the problem was quickly corrected, and she gave birth to her son Jack without incident five months later.

"The fact that they could go through my nose and not open my head was wonderful," she said.

Specialty suite

In a sign of support for the approach, UPMC opened a new operating room designed for endoscopic brain surgery earlier this month. It is believed to be the first of its kind in the nation.

The suite, a collaboration between UPMC and Karl Storz Endoscopy-America Inc., uses the latest electronic systems to coordinate a variety of imaging technology, including the display of endoscopic images in the operating room and nearby observation areas and offices. The interactive technology also allows surgeries to be telecast worldwide.

UPMC officials believe the investment will help realize the surgery's potential, said James Terwilliger, vice president of operations for UPMC Presbyterian. "We think a program like Dr. Kassam and Dr. Snyderman have developed will have a national draw."

Charlie Wilhelm, president of Karl Storz Endoscopy-America, said endoscopic neurosurgery also offers a growth opportunity for the company. Like other types of surgery, neurosurgery is moving increasingly toward minimally invasive procedures, he said.

The endonasal approach also has generated considerable interest among surgeons. The first World Congress on endoscopic brain and spine surgery, chaired by UPMC physicians, drew more than 350 people from 32 countries to the David L. Lawrence Convention Center earlier this month.

While other doctors are performing endonasal brain surgery, those at UPMC "probably have one of the largest experiences in the world," said Dr. Jatin Shah, program director for head and neck surgery at Memorial Sloan-Kettering Cancer Center in New York.

In the 1990s, Dr. Hae-Dong Jho, working in collaboration with Dr. Carrau, began using an endoscope at UPMC for through-the-nose surgery on the pituitary gland, which sits in a pocket of bone at the base of the skull. Dr. Jho, who now practices at Allegheny General Hospital, and Dr. Carrau reported their experience with 50 patients in 1997.

In 1998, Drs. Kassam and Snyderman began using the same endoscopic techniques and have since expanded transnasal surgery to new levels, said Dr. Joseph Maroon, professor and vice chairman of neurological surgery at UPMC.

"Worldwide, they are clearly in the forefront," he said.

Mastering the surgery has been challenging, Dr. Snyderman said, noting that even understanding the views through the endoscope was difficult at first.

"There are no anatomic books for surgeons that describe the anatomy we see, "he said. "This view of it was new."

They also had to develop new surgical instruments that fit the nose, many of them named after Dr. Kassam's two sons Mikaeel, 5 and Armand, 10. A set is dissectors is named after Mikaeel, while a device to hold the endoscope is known as the Armand Holder..

Dr. Kassam said pioneering results achieved by his group include the first reported removal through the nostril of a tumor inside the spine, as well as transnasal removal of tumors in areas that control swallowing and tongue movement.

Moreover, nearly all patients who have had surgical removal of meningiomas and craniopharyngiomas have had improvement or stabilization of their preoperative vision problems, he said, noting that vision loss after standard surgeries to remove those tumors is an uncommon but possible side effect.

Dr. Shah of Sloan-Kettering said the potential for the surgery in benign tumors is extraordinary, noting that potential complications are minimized significantly.

But use of the surgery for malignant tumors is less clear, he said, because it could be more difficult to leave margins of healthy tissue around tumors or to ensure that malignant tissue is not left behind.

Experts in the technique need to share their experience with those tumors, he said, as well as develop training programs and work together to compile data.

Dr. Kassam said an international consortium of endoneurosurgeons has been created to share data. That group is preparing information to help doctors gain expertise in performing the surgery, he said, noting that the learning curve is steep.

Rapid advances in technology "are enabling us to undertake procedures that we once thought unimaginable," he said.

"The evolution of technologies, in combination with long-term patient outcomes, will determine the eventual role of this procedure within the scope of neurosurgery."