Think Neuro Podcast: A Tiny Tunnel to the Brain & Pituitary: Minimally Invasive Brain Surgery and The Origins of our Institute
by Anthony Effinger
The Think Neuro podcast from Pacific Neuroscience Institute takes you into the clinic, operating room and laboratory with doctors and surgeons who are tackling the most challenging brain diseases and disorders. Host: Anthony Effinger
In this podcast, Dr. Kelly talks about how he was drawn to neurosurgery, his fascination with the pituitary gland, the nuances of minimally invasive pituitary and brain tumor surgery, as well as a brief history of PNI, its focus on innovation and clinical trials and its 8 centers of excellence.
Today’s topic is Endoscopic Pituitary and Keyhole Brain Tumor Surgery & the Formation of PNI. Dr. Daniel Kelly talks about how he became drawn to neurosurgery, his fascination with the pituitary gland, the nuances of minimally invasive pituitary and brain tumor surgery, as well as a brief history of PNI, surgery, as well as a brief history of PNI, and its centers of excellence.
Anthony Effinger (01:00):
Thanks for sitting down with me today.
Dr. Daniel Kelly (01:01):
Anthony Effinger (01:01):
How are you?
Dr. Daniel Kelly (01:03):
Anthony Effinger (01:04):
Dr. Daniel Kelly (01:04):
How are you doing?
Anthony Effinger (01:04):
Great. Great. Thanks for making yourself available.
Dr. Daniel Kelly (01:08):
Anthony Effinger (01:08):
So, I want to know, just to start off, tell me a little bit about your practice.
About Dr. Kelly
Dr. Daniel Kelly (01:12):
So my practice is neurosurgical practice. My focus is really in brain tumors, all types of brain tumors, so from the benign to the malignant. And that encompasses a wide spectrum of diagnoses. Patients come in with all sorts of different neurological complaints.
Dr. Daniel Kelly (01:31):
Occasionally, they are discovered incidentally, someone may get a scan for say a headache and they discover an abnormality and then they come to us. In many of those cases we just reassure them that there’s nothing that needs to be done other than follow up with regular scans, but occasionally someone gets a serendipitous scan and they end up having to have surgery.
Anthony Effinger (01:53):
Oh my. When did you know you were going to be a neurosurgeon?
Dr. Daniel Kelly (01:59):
Not too long ago actually. It wasn’t planned actually… in some instances people plan for years and years or think about it, but I came to it in sort of a slow, very, very methodical in some ways haphazard process I suppose.
Dr. Daniel Kelly (02:18):
In high school I was very interested in the biological sciences, in college, I got extremely interested in the neurosciences and actually the evolution of human intelligence. As I was thinking about what to do, I was also actually interested in marine biology and I was thinking about going and getting a PhD in marine biology and ultimately, I decided to go to med school to postpone a decision.
Dr. Daniel Kelly (02:46):
I thought there were so many opportunities in med school that I would find something that I really would gravitate to and I kept coming back to the neurosciences and to surgery. And neurology, although a wonderful field, very diagnostically oriented, lots of great tools and technology. But I really like the hands-on and the sort of athleticism and art of surgery.
Dr. Daniel Kelly (03:18):
And given where we are in terms of neurosurgical advances, I thought that that was really an area where I could be stimulated and creative for a long time and be challenged. And so it became over time through med school more and more clear that neurosurgery would be the way to go.
Anthony Effinger (03:43):
You said an athleticism, I think it really is. It’s a feat of…
Dr. Daniel Kelly (03:48):
Yeah, you can’t be a total klutz. You have to have some decent hand-eye coordination, you have to have a certain amount of finesse, you have to have a certain… patience is really key and you have to do a lot of training, and have some endurance.
Dr. Daniel Kelly (04:09):
Because a lot of our procedures are quite long.
Anthony Effinger (04:12):
Dr. Daniel Kelly (04:12):
Well, a typical brain tumor operation is anywhere from three to six hours, but then some go eight to 10 or 12 hours.
Anthony Effinger (04:24):
Dr. Daniel Kelly (04:24):
And so you need the ability to maintain focus and to remember what’s critical and keep the goals of the operation in mind. One of the big things also is the decision making, how far do you go? Because a lot of times we deal with tumors that are perhaps a very stuck or adherent to blood vessels or critical nerves or the brain itself, and you have to decide when to stop.
Dr. Daniel Kelly (04:58):
If you leave a lot of tumor behind that may impact the patient negatively. But if you go for broke, so to speak, if you really try to take everything out, you can end up hurting patients, you can wind up with a stroke, you can wind up with impaired vision that they didn’t have.
Dr. Daniel Kelly (05:17):
It’s a very fine line. And that decision making is key and you have to sort of maintain your sharpness throughout an operation so that you don’t veer off into an area where you shouldn’t have gone.
Anthony Effinger (05:31):
Were you always good with your hands?
Dr. Daniel Kelly (05:35):
I did a lot of sports when I was younger. I skied a lot. I played tennis a lot. I actually wrestled [crosstalk 00:05:46].
Anthony Effinger (05:46):
It’s valuable for neurosurgery.
Dr. Daniel Kelly (05:47):
I was a county champion at 76 pounds-
Anthony Effinger (05:52):
Dr. Daniel Kelly (05:53):
… in eighth grade in Arapahoe County and-
Anthony Effinger (05:57):
Dr. Daniel Kelly (05:57):
… suburban Denver. You being from Colorado or-
Anthony Effinger (06:00):
Yeah. [crosstalk 00:06:01].
Dr. Daniel Kelly (06:01):
So yeah, I did a fair amount of sports and not overly committed, but it was a part of my, part of my life. I played tennis for one year in college in Claremont.
Anthony Effinger (06:17):
You have a history of athleticism.
Dr. Daniel Kelly (06:20):
Dr. Kelly’s Neurosurgery Training
Anthony Effinger (06:21):
Yeah. And how was it for you a training as a neurosurgeon? Is it as rigorous and demanding and…
Dr. Daniel Kelly (06:28):
Yeah, I went to med school at Georgetown and then I did my training at GW from 86 until 93. The training is such that you initially, this was back in the days when there was no resident hour rules, so-
Anthony Effinger (06:53):
Dr. Daniel Kelly (06:54):
… call was really you spent a lot of time in the hospital and we would do stents where we were on every other night call-
Anthony Effinger (07:01):
Oh my God.
Dr. Daniel Kelly (07:02):
… which would be fairly exhausting. And there was a lot of sleep deprivation, but I, I liked it. I really enjoyed it. There were days where you just couldn’t believe your beeper was going off again, at two in the morning, at four in the morning, and this just interrupted sleep day after day, and probably not great for you, but that’s the way training is or certainly the way training was.
Dr. Daniel Kelly (07:29):
And I think the thing about training is that I found that people that were really thriving and intuit had a realistic expectations. That people that didn’t have realistic expectations, they were going to maybe be able to go home and live their life. They weren’t very happy.
Anthony Effinger (07:46):
So you knew this was going to be like bootcamp for-
Dr. Daniel Kelly (07:49):
Yeah, I think most people understand that. Yeah, the training is a very interesting process. They say, “See one, do one, teach one.” That sort of phrases is true to some degree and it’s a very hands on, very raw experience. Being at trauma centers I was at, you see a lot of amazing kind of horrific stuff and some really beautiful stuff. People having amazing outcome.
Dr. Daniel Kelly (08:19):
The training in neuroscientist, particularly neurosurgery in general, there’s this incredible spectrum of pathology and people going through some really, really tough stuff and then some really amazing, amazing outcomes.
Anthony Effinger (08:33):
Do you remember your first neurosurgery?
Dr. Daniel Kelly (08:37):
I remember one attending at GW who was a real kind of classic jerk in the operating room. He was a jerk to everyone. He was very condescending, he did stuff that today he would be off the medical staff a week.
Anthony Effinger (09:03):
Dr. Daniel Kelly (09:04):
Yeah. Abusive to the nurses but in incredibly good surgeon, very thoughtful. And I learned a lot from the guy. I didn’t learn his behavior, I didn’t pick that up. But I remember doing my first craniotomy with him and he-
Anthony Effinger (09:27):
Dr. Daniel Kelly (09:28):
Taking some bone away from the head to get in and remove a tumor. I believe we were doing that and he didn’t like the way I was holding an instrument and just gave me a super hard time for that. So my second year of training after my surgical internship and then doing my first year. Yeah, he was hard on everyone, but you get used to that.
Anthony Effinger (09:55):
I bet you never held it that way again.
Dr. Daniel Kelly (09:58):
No, I didn’t. Yeah.
Anthony Effinger (09:58):
Dr. Daniel Kelly (09:59):
The Pituitary Gland
Anthony Effinger (10:00):
Then how long did you practice before you became interested in the pituitary gland?
Dr. Daniel Kelly (10:05):
Well, that started when I was a resident, largely due to my mentorship with Ed Laws who is still practicing wonderful guy, father figure to me in a lot of ways, just an amazing man, perhaps the biggest name on the planet in pituitary surgery.
Dr. Daniel Kelly (10:23):
And he was also the editor of one of the neurosurgical journals back then. It was called the Red Journal, and he just a wonderful mind, brilliant kind of a Renaissance man. And he really got me excited about the pituitary gland and pituitary tumors. And I just thought that, “It was such a fascinating area.”
Dr. Daniel Kelly (10:50):
It’s really at the intersection of the mind and the body. Being the master gland, it controls all the body’s hormones. And it’s so small and so delicate and in this space that’s surrounded by all these critical structures, including the carotid arteries, the optic nerves, the brainstem, and yet it’s accessible through the nose. Imagine that.
Anthony Effinger (11:16):
I was looking at a diagram of the brain and where the pituitary lives. It’s like the crossroads of every important thing in your body.
Dr. Daniel Kelly (11:26):
Anthony Effinger (11:26):
Right? And it’s the size of a pea, is that correct?
Dr. Daniel Kelly (11:28):
Yeah, just about lima bean maybe.
Anthony Effinger (11:30):
Like on a good day?
Dr. Daniel Kelly (11:31):
On a good day, yeah.
Anthony Effinger (11:32):
So what goes wrong with the pituitary that we need to fix surgically?
Dr. Daniel Kelly (11:38):
So the pituitary gland is a site of many tumors, benign tumors, what we call pituitary adenomas and they’re actually the third most common intracranial tumor behind meningiomas, which has benign tumor in gliomas and pituitary tumors are number three.
Dr. Daniel Kelly (11:55):
And so there’s a lot of patients develop adenomas and either they typically cause pituitary gland hormonal dysfunction. Either they produce too many hormones, so you get an excess say of cortisol in your body or an excess of growth hormone or an excess of prolactin. Those are all individual syndromes.
Dr. Daniel Kelly (12:20):
As they get bigger, they cause what we call symptoms of mass effect. So as the tumor gets bigger, it compresses the normal gland and so you can get loss of pituitary gland function, the gland can fail. So you can develop all those things like low thyroid, low testosterone, women’s their periods can stop. Men or women can become infertile.
Anthony Effinger (12:44):
And this is because this is the master gland-
Dr. Daniel Kelly (12:46):
Anthony Effinger (12:47):
… it encompasses so many other things.
Dr. Daniel Kelly (12:48):
So as it’s growing [crosstalk 00:12:49]. Yeah, the outflow signals, the hormones that are supposed to be being sent out by the pituitary gland they stop or they go to such low levels, you become symptomatic and you develop these pituitary insufficiencies or deficiencies.
Dr. Daniel Kelly (13:05):
So, the other two things that can happen is you can get vision loss because as the tumors grow, they grow upward and they hit the optic chiasm directly above the pituitary gland.
Dr. Daniel Kelly (13:17):
So a classic syndrome of an enlarging pituitary adenomas, what we call a bitemporal visual field defect, meaning where you lose your peripheral vision because the fibers that are hit classically are in the midline where the nerves cross and that’s where your peripheral vision in each eye that data gets transferred back to your occipital lobe-
Anthony Effinger (13:45):
Dr. Daniel Kelly (13:46):
So vision loss, loss of pituitary gland function, and then headaches. Headaches are a common, obvious they are very common. There’s a typical type of a pituitary headache where people usually say it’s in the front of the head above the nose here, above the eyes. And it’s the classic pituitary type headache.
Dr. Daniel Kelly (14:05):
Yeah, so it causes those symptoms of mass effect headache, loss of vision, pituitary gland dysfunction. And then there’s the overproduction of what we call the endocrine active pituitary adenomas, where they’re making too much of something.
Anthony Effinger (14:24):
Is an adenoma malignant or nonmalignant?
Dr. Daniel Kelly (14:27):
Anthony Effinger (14:27):
Okay. They’re benign.
Dr. Daniel Kelly (14:28):
They’re almost all benign.
Anthony Effinger (14:29):
But they’re in the way.
Dr. Daniel Kelly (14:30):
They’re in the way. And some of them are bad actors. So there are what they used to call atypical pituitary adenomas they reclassified them, but there’s a subset of pituitary adenomas. They don’t really behave like a cancer, but they’re aggressive and they’re more invasive.
Dr. Daniel Kelly (14:46):
They can get out around, say the carotid artery, they can get out around the cranial nerves that move the eye into this area called the cavernous sinus. Even some of the very benign ones can be invasive. They’re invading into that space. And so they’re very benign, slow-growing, but they’re in places where we can’t get them all. So then they may need not only surgery, they may need radiation or in some instances, other treatments.
Anthony Effinger (15:13):
Is there anything that predisposes somebody? Do we know anything about the causes?
Dr. Daniel Kelly (15:17):
Anthony Effinger (15:17):
It just happens.
Dr. Daniel Kelly (15:19):
As far as we can tell. Yeah, there are some cases associated with prior radiation. People had radiation, but that’s pretty rare. And radiation-induced tumors in the head tend to be things more like meningiomas, occasional gliomas, other types of-
Anthony Effinger (15:36):
Not these necessarily?
Dr. Daniel Kelly (15:37):
No, no it’s not-
You’ve Found a Pituitary Tumor, Now What?
Anthony Effinger (15:40):
Okay. What do you do then? If somebody comes in, they’ve presented with this headache or something else like that. You’ve scanned them. They have-
Dr. Daniel Kelly (15:46):
A pituitary tumor?
Anthony Effinger (15:47):
Dr. Daniel Kelly (15:48):
And so yeah, they come in and they have vision loss and they have a large tumor. Say that that needs removal, then we remove it.
Endoscopic Endonasal Surgery forPitutiray Tumor Treatment
Anthony Effinger (15:58):
Is it always a surgical solution in this case or you said that sometimes it’s not?
Dr. Daniel Kelly (16:02):
So for all of the pituitary adenomas except one type, if it’s symptomatic, the first-line treatment is endonasal endoscopic removal.
Anthony Effinger (16:12):
Endonasal through the?
Dr. Daniel Kelly (16:13):
Through the nose with an endoscope.
Anthony Effinger (16:15):
Dr. Daniel Kelly (16:15):
Yeah. Surgical telescope using both nostrils. And the goal is-
Anthony Effinger (16:19):
Meaning okay, one for one.
Dr. Daniel Kelly (16:21):
So we have the endoscope in one nostril and then we have instruments working through both nostrils. And the anatomy of the nose is such that if you remove a little bit of the back of the septum, way in the back that’s not structurally significant and you opened what are called the sphenoid ostia.
Dr. Daniel Kelly (16:41):
There’s two openings into the sphenoid sinus, which is an air sinus behind the nasal cavity and right up against the pituitary gland. If you remove the back of the septum and you make those two openings into one bigger opening, then you have this big working corridor, relatively big-
Anthony Effinger (16:56):
I was going to say-
Dr. Daniel Kelly (16:57):
… do it through-
Anthony Effinger (16:59):
… what’s big for you?
Dr. Daniel Kelly (17:00):
… with a four millimeter endoscope is the diameter of this high definition beautiful surgical telescope. And then we have these very low profile instruments that are working through both nostrils and the two surgeons are looking at-
Anthony Effinger (17:17):
Dr. Daniel Kelly (17:18):
… the monitors. It’s team surgery.
Anthony Effinger (17:19):
Why is that?
Dr. Daniel Kelly (17:21):
Well, because you have to have someone drive the endoscope. Back in the day, we did and I did it that way for many years with an operating microscope. So the operating microscope came into neurosurgery in the 60s and it really changed neurosurgery in a wonderful way because you could see things better than say with a headlamp as you can imagine this fine structures that we need to see.
Anthony Effinger (17:44):
Dr. Daniel Kelly (17:45):
So the surgical microscope was a huge advent, but in the 90s started using endoscopes.
Anthony Effinger (17:51):
You can talk to me about a camera on the end of a…
Dr. Daniel Kelly (17:53):
On the end of a stick?
Anthony Effinger (17:54):
Dr. Daniel Kelly (17:54):
Anthony Effinger (17:55):
Is the stick bendy?
Dr. Daniel Kelly (17:56):
Well, there are flexible endoscopes, but the optics are so much better with the rigid endoscopes and they lend themselves very well to endonasal surgery that we use only the rigid endoscopes.
Anthony Effinger (18:08):
Is that because it’s a straight shot?
Dr. Daniel Kelly (18:09):
It’s a straight shot from the nose to the base of the skull. And now because of the advent of endoscopy and a number of other things, we can address and remove a whole variety of tumors that are in or around the pituitary gland and all around the skull base from low down to high up.
Dr. Daniel Kelly (18:31):
And so all, there’s a whole spectrum of midline, what we call midline brain tumors that we can remove through the nose now, and that’s been one of the biggest changes in the last 20 years, this advent of endoscopic-
Anthony Effinger (18:49):
Dr. Daniel Kelly (18:49):
… slow base surgery.
Anthony Effinger (18:50):
… when you talked about the, what did you call it? The microscope.
Dr. Daniel Kelly (18:53):
Anthony Effinger (18:54):
You can’t get that into where the pituitary is?
Dr. Daniel Kelly (18:57):
You can’t put the microscope in, but you can put a… Imagine if you put a speculum in the nose, in a nostril or they used to do it under the lip was called a sublabial approach. So you couldn’t go in through this opening. If you look at a skull, you can see what’s called the pyriform aperture.
Dr. Daniel Kelly (19:12):
Your nose is cartilage and skin. So if the the old approach was to make an incision just above the incisors here and open up into this mucosa. If you put a speculum in, you push the septum to one side, you can get all the way back to the skull base and to the pituitary gland. And that was the way it was done forever. That’s the way Harvey Cushing did it at that.
Dr. Daniel Kelly (19:40):
So through the pyriform aperture, this is what this is called. And going back, you can imagine this is where the pituitary gland lives right here and the optic nerves are coming out here and the carotid arteries are coming up along the side here. So it’s a very, very busy high rent.
Anthony Effinger (19:55):
It is high rent.
Dr. Daniel Kelly (19:55):
But this really revolutionized pituitary surgery. So using an operating microscope. But then starting in the, in the mid to late 90s, we started using endoscopes, and we certainly weren’t the first to do it. There were a number of pioneers in this area.
Dr. Daniel Kelly (20:13):
And the endoscopic approach over time has really won over simply because you can see better. And as optics have gotten better and we have high definition scopes, the view we get with the endoscope is amazing.
Dr. Daniel Kelly (20:30):
But to be fast, say I want to be 200 micro neurosurgeons, someone has to drive the scope and then someone has to operate. So the paradigm now, the way we do this now is we have two surgeons. My ENT partner is Dr. Chester Griffis who’s a fantastic and wonderful surgeon.
Dr. Daniel Kelly (20:54):
And so the majority of the cases that we do with our pituitary team, my partner, Dr. Barkhoudarian is using this fully what we call a fully endoscopic approach. For many years, I was using an endoscope assisted approach. We’d start with the microscope and then we’d switch over to the endoscope.
Dr. Daniel Kelly (21:13):
And actually for brain tumor surgery, which we may talk about later, is we often do endoscope assisted approaches. We start with a microscope and then we bring the endoscope in to look around corners. And the beauty of the endoscope is not only is it high definition up-close view, it allows you with an angled lens to look around corners so you can see things that you couldn’t otherwise see.
Dr. Daniel Kelly (21:35):
And it allows you to do a lot of stuff without retracting the brain. So, we’ve applied a lot of endoscopy techniques into intracranial brain tumor surgery, and that’s one of the things that we’re really known for here at PNI, and one of the things that we’ve really pushed the envelope on.
Dr. Daniel Kelly (21:53):
But suffice it to say this approach through the nose with an endoscope using both nostrils, no incisions on the face is the way we remove 98, 99% of all pituitary adenomas and the way we remove vast majority of a bunch of other tumors that can occur anywhere in the midline here.
Anthony Effinger (22:16):
Dr. Daniel Kelly (22:16):
And the reason we can’t go too far off the midline is because we have structures like the carotid arteries and the optic nerves where it’s safer and better to come from above through a different approach.
Anthony Effinger (22:26):
Now, do you take turns? Does one surgeon drive sometimes and one person?
Dr. Daniel Kelly (22:31):
Anthony Effinger (22:31):
Dr. Daniel Kelly (22:32):
Yeah. But the air nose and throat surgeon, we don’t like to let them get close to the brain. No, the reality is that the ENT or the otolaryngologist will drive the scope. They’re really a key member of the team because they do the approach.
Anthony Effinger (22:52):
What do you mean do the approach? They do the actual
Dr. Daniel Kelly (22:55):
Meaning get us there. Yes.
Anthony Effinger (22:56):
Dr. Daniel Kelly (22:57):
And that’s an also an area where we’ve really pushed the envelope on being very careful not to disturb the normal anatomy. The old approaches with the endoscope and still in many places, I’d say they’re not necessarily very gentle on some of the tissues and the rates of people losing their sense of smell and other issues related to removing tissue become significant problems for the patients postoperatively.
Dr. Daniel Kelly (23:28):
So we do a technique, it’s an incisional technique where we’d simply incise the mucosa. We want to be extremely careful to preserve olfaction, the sense of smell and we know where the olfactory fibers are coming down. And so, we are very careful with the way the cuts are made. We’re very careful with the blood vessel supply.
Dr. Daniel Kelly (23:50):
And so it’s almost like in a series of incisions and drapes where you push everything out of the way. Then we remove the bone that we need to-
Anthony Effinger (23:58):
The bone in the…
Dr. Daniel Kelly (23:59):
At the back of the nasal cavity.
Anthony Effinger (24:01):
And it’s a little that small.
Dr. Daniel Kelly (24:02):
It’s pretty small. And doing all that, certainly requires finesse and skill and that’s what Dr. Griffis does and his colleagues, Dr. Karimi and Dr. Pierce. But that approach then getting us there is really a key part. And then once we get inside the sphenoid sinus, we do the exposure over the pituitary gland or wherever the tumor is. And then we go in and take the tumor out.
Anthony Effinger (24:33):
When you’re in there, you see the tumor, right? And you’re like, “Okay.” How does it get it out?
Dr. Daniel Kelly (24:39):
I can’t tell you.
Anthony Effinger (24:41):
That’s the trade secret?
Dr. Daniel Kelly (24:42):
Anthony Effinger (24:42):
Dr. Daniel Kelly (24:43):
For pituitary adenomas, the distinction between the normal gland and the adenomas is usually pretty clear. We pay a lot of attention to the MRIs before surgery. Patients will get a high quality, high definition MRI, the pituitary gland and it will show how the tumor is related to the normal gland and where it is in relation to the carotid arteries and the optic nerves.
Dr. Daniel Kelly (25:08):
And so all that data we use obviously when we go in and we know where to find it. And then when we remove the bone in front of the gland, then we open the dura. Before we do that, we always listen for the carotid arteries because we want to make sure we don’t injure the carotid arteries as we’re opening the dura, which is a very well known complication of this surgery.
Dr. Daniel Kelly (25:31):
So the Doppler probe is very helpful for helping us know exactly where they are.
Anthony Effinger (25:35):
The Doppler probe is a listening device [crosstalk 00:00:25:38].
Dr. Daniel Kelly (25:39):
Yes, it’s like an a long flexible tip. And we also use navigation,it’s like GPS for the brain. So we have a probe that will tell us where we are. The problem is the navigation is based off of the CT scan or the MRI and it can be off by a few millimeters. So the Doppler probe in terms of localizing the carotid artery in our opinion, is much more accurate in real time.
Dr. Daniel Kelly (26:01):
So because we can put it and we can direct it and it’ll tell us exactly where it is, and it allows us to do a very wide but safe opening of the dura that covering to the brain, the pituitary. And then in many, if not most instances, we’ll be looking at the tumor, it will be right there and maybe the gland is like a Crescent moon or like the peel of an orange.
Dr. Daniel Kelly (26:22):
And so then we go in with a variety of little micro-instruments and we peel the tumor away from the gland. For the large tumors, we will tend to remove the lower half of the tumor first to take the pressure off of the optic nerves and the surrounding structures.
Dr. Daniel Kelly (26:40):
And then we do a dissection around the capsule of the tumor and pull it away from the gland being very gentle on the gland with the goal being a total removal and protecting the gland and it actually improving the function of the gland by taking the pressure away from it.
Anthony Effinger (26:56):
So the material from the tumor comes out, you take that out of the body.
Dr. Daniel Kelly (26:59):
We have a variety of the little grasping a tumor grasping forceps or biopsy forceps. We gently pull the tumor away from the normal structures and it all comes out. And some of the times it goes up the suction of course. Yeah. We have suction to keep the blood out of the way.
Anthony Effinger (27:17):
That suction is in there as well?
Dr. Daniel Kelly (27:19):
Anthony Effinger (27:19):
There’s a lot. So a lot of instruments are going into this.
Dr. Daniel Kelly (27:21):
Usually, so you have the endoscope in one nostril, you have a suction in one nostril and then you have a working instrument in the othe. There’s always a suction there because there’s always oozing and bleeding going on and fluid and we have to irrigate.
Dr. Daniel Kelly (27:36):
We have to irrigate with saline to flush the blood away to help see better. And I’m very important to keep up. You can’t keep up quote a bloodless field, but you want to keep as much blood out of the field as possible because it actually absorbs the light and it makes your endoscopic view much darker.
Anthony Effinger (27:55):
What’s in your hands when you’re doing this?
Dr. Daniel Kelly (27:57):
I’m holding instruments, and so it could be a micro scissor, it could be something called a ring curate which is what we use to dissect the tumor away from the gland.
Anthony Effinger (28:09):
What is keyhole surgery?
Dr. Daniel Kelly (28:13):
Keyhole surgery is a term that we use to describe this minimally invasive approach with less collateral damage to the key structures really starting on the outside from the scalp, muscle, the bone, the covering to the brain, and then ultimately of course to the cranial nerves, the blood vessels that supply the brain and the brain itself.
Dr. Daniel Kelly (28:37):
And so it’s using these minimally invasive approaches through typically smaller openings to essentially sneak in and sneak out, remove a tumor as completely as possible without causing any harm.
Dr. Daniel Kelly (28:55):
And so we have developed all these approaches over time. And say we, the collective we, the people that are really pushing this minimally invasive movement in neurosurgery and the approaches that we use are through the nose that we’ve talked about quite a bit.
Dr. Daniel Kelly (29:15):
The endoscopic endonasal approach, the supraorbital craniotomy, the retro mastoid approach and these gravity assisted approaches. And all of those, allow us to get to places that you could get to and in many places they do with the more traditional larger craniotomy.
Dr. Daniel Kelly (29:34):
And we’ve really been pushing this with using the endoscope, using low profile instrumentation, using a navigation and as you do these more and more, doing pituitary surgery for many, many years through the nose, you get used to working in a very small space and you just don’t need much room. And the traditional skull base approaches, which are still taught and talked about a lot.
Anthony Effinger (30:04):
I was going to ask, what percentage of people are pursuing the minimally invasive keyhole techniques?
Dr. Daniel Kelly (30:10):
I’d say it’s more and more people are doing it. Is it common practice? No, because I see referrals all the time coming from some of our local institutions here where they’re getting recommended these very traditional big approaches.
Dr. Daniel Kelly (30:29):
It frankly surprises me. Those approaches are still being taught at a lot of the training programs. They’re discussed at meetings. But there’s this other side, there’s, there’s a bunch of us doing this and pushing the envelope on there.
Anthony Effinger (30:44):
What year did you start doing minimally invasive keyhole?
Dr. Daniel Kelly (30:47):
There’s not some point where we just started doing it. I’ve been pushing it for 20 plus years. I would say we’ve learned a lot. We’ve gotten much better. We’ve published a lot. We use these keyhole approaches for the vast, vast majority of all the brain tumors we take care of now including pituitary tumors. So the vast majority do not require, in our opinion, a big traditional craniotomy.
Anthony Effinger (31:15):
But it sounds like other people are still doing these big traditional craniotomies.
Dr. Daniel Kelly (31:19):
Anthony Effinger (31:20):
Dr. Daniel Kelly (31:20):
A lot of them. Yes.
Anthony Effinger (31:22):
So people are getting big holes. Put in their head to get these things from you.
Keyhole Surgery Recovery
Dr. Daniel Kelly (31:26):
In many incentives, the operations go very, very well. And in our opinion, this is a better way to do it. It’s patients get a great tumor resection with less brain retraction and many instances with less collateral damage and they’re out of the hospital very quickly.
Anthony Effinger (31:52):
How quickly, what are we talking about?
Dr. Daniel Kelly (31:53):
So the average is two days, but sometimes it’s the day after surgery and-
Anthony Effinger (31:58):
Two days for brain surgery.
Dr. Daniel Kelly (32:00):
Yeah. The majority of our patients with benign brain tumor. If you take pituitary adenomas meaning are going home in two days. Yeah. And some go home in one day,
Anthony Effinger (32:08):
The day after surgery you go home.
Dr. Daniel Kelly (32:11):
You take it easy.
Anthony Effinger (32:12):
Don’t go out and don’t go surfing the next day say
. Yeah. Yeah. What is the recovery?How long are you sort of…
Dr. Daniel Kelly (32:18):
So we typically tell people, you take it easy the first week. Plenty of walking is good, nothing too strenuous. You can be a little more active the second week, you can drive after two weeks and after three weeks you can do anything.
Anthony Effinger (32:32):
Dr. Daniel Kelly (32:32):
Anthony Effinger (32:33):
Do you have to change your cognitive, like reading any of that? It’s not like a concussion they warn people now, not to.
Dr. Daniel Kelly (32:39):
It depends on what you have, what kind of tumor you have and how you were doing beforehand.
Anthony Effinger (32:48):
Okay. I can’t believe that hat’s what we’re… because the less time in the hospital is the better, right?
Dr. Daniel Kelly (32:53):
Anthony Effinger (32:53):
These days. Okay.
Dr. Daniel Kelly (32:53):
Anthony Effinger (32:54):
So you were at UCLA and tell me how you came to start a Pacific Neuroscience Institute.
Dr. Daniel Kelly (33:00):
So I came in 2007 after a couple of years of considering my options and seeing a great opportunity at the John Wayne Cancer Institute, which was actually part of UCLA until 1991 when the entire institute moved over to St. John’s front page, LA Times News apparently.
Dr. Daniel Kelly (33:18):
So in 2007, I finally moved over to the John Wayne with the idea of starting a brain tumor program and a neuro-oncology program. And I started really came by myself but was colleagues with Howard Krauss and Chester Griffis.
Dr. Daniel Kelly (33:31):
And over time, we worked together, I brought in the junior partner Garni Barkhoudarian, Chester and Howard’s practice grew. And we saw the need and the opportunity to build a bigger program and we wanted our own neuro-oncology division, neuro-oncologists. And so we recruited Santos Casey, who’s one of the other four founders who I’m sure you’ll talk to at some point.
Dr. Daniel Kelly (33:54):
And so we recruited Santos from UC San Diego in 2015, and as that happened, we started to conceptualize the idea of Pacific neuroscience institute and expanding into these other areas. We’re starting to work with George Teitelbaum, who’s one of our neurointerventionalists to develop a stroke program.
Dr. Daniel Kelly (34:16):
And we also saw that we were doing a lot of stuff that was not necessarily brain tumor related and cancer related, and we felt the need to develop a new institute. So that’s how Pacific Neuroscience Institute started.
Dr. Daniel Kelly (34:30):
So it really budded off of the John Wayne in a way, and we’re still all part of the John Wayne and those of us that are in doing tumor work. But the institute now has eight clinical centers of excellence and a research center. We have over 30 MDs, we have a bunch of PhDs, we do a lot of clinical trials, we do fellowship training and our institutes now are centers of excellence now really cover the full spectrum of neuroscience disorders.
Dr. Daniel Kelly (35:03):
So not only you know tumors but stroke, hydrocephalus, facial pain, movement disorders, and most recently brain health, which I think is going to be one of the most interesting.
Anthony Effinger (35:15):
What’s in there?
About the Pacific Brain Health Center
Dr. Daniel Kelly (35:17):
So within brain health, the initial big focuses has been on dementia and cognitive issues, but we’re also expanding into other things like anxiety and depression and addiction. We’re building a program in psychedelic assisted therapies. There’s a huge Renaissance going on in psychedelics right now, particularly with psilocybin and MDMA, and we’re going to be part of those-
Anthony Effinger (35:43):
Dr. Daniel Kelly (35:44):
… clinical trials. And we feel that, that’s just a really important for any neuroscience entity to be involved in. I think that this area of psychedelic assisted therapies is potentially the most interesting and impactful area of the neuroscientists right now.
Dr. Daniel Kelly (36:02):
It has great potential to totally transform behavioral health care because there’s just so many people that are impacted with anxiety, depression, addiction, PTSD, and the current therapies simply they work, but they’re not great.
Dr. Daniel Kelly (36:17):
And I think there was so much good science being done back in the 50s and 60s and early 70s and it all got buried for the reasons we all know, but fortunately it’s coming back and we’re going to be part of that.
Anthony Effinger (36:31):
So how do you like having an institute with everybody in one building or very close to each other and you got all this expertise? Does that help you do your specialty?
Dr. Daniel Kelly (36:40):
Anthony Effinger (36:41):
Yeah. That’s fantastic. I thank you so much for your time. It’s been a delight. Dr. Kelly [crosstalk 00:00:36:45]. Thank you. Yeah. Pleasure.
Dr. Daniel Kelly (36:46):
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About the Author
Think Neuro host Anthony Effinger is an award-winning health journalist who is fascinated with neuroscience and the workings of the brain. He won 1st Place in the 2006 Awards for Excellence in Health Care Journalism, from the Association of Health Care Journalists, for Playing the Odds, a piece on the various strategies used to treat prostate cancer.
Last updated: April 27th, 2020