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
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
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