Outpatient Brain Tumor Surgery Feasible, Safe

Nancy A. Melville

July 08, 2020

As an ever-increasing number of complex surgeries are regularly being performed in an outpatient setting at ambulatory surgical centers, some brain tumor resections may be safe and feasible for appropriately selected patients, new research suggests.

Unadjusted results from a large feasibility study that included more than 300 patients who underwent craniotomy for resection of meningioma showed that among those who were treated in an outpatient setting, mortality and complication rates were significantly lower than for their inpatient counterparts.

Although adjusted analysis showed that between-group differences were no longer significant, outpatient surgery was still not associated with increased mortality or adverse events (AEs).

In addition, patients with low comorbidity rates appeared to be the group "most suitable for outpatient treatment," the investigators note.

"This is one of the first analyses using US data that shows that select neuro-oncology patients could benefit" from outpatient surgery, lead author Nikita Lakomkin, MD, Icahn School of Medicine, Mount Sinai Health System, New York City, told Medscape Medical News.

The study "has implications for patients, who often prefer to be treated close to home near their family, as well as reducing the overall cost of care," Lakomkin added.

The findings were presented at the virtual American Association of Neurological Surgeons (AANS) 2020 Annual Meeting.

Brain Surgery During COVID-19

Ambulatory surgical centers offer significant cost savings and convenience and have gained favor among clinicians and patients alike.

During the COVID-19 pandemic, services provided outside of hospitals confer the added benefit of potentially preventing hospital exposure to the virus.

Neurosurgery has already made its way to the centers, most notably in regard to spinal procedures.

Although neuro-oncology often involves highly complex operations better suited for the in-hospital setting, there are exceptions. For example, craniotomies for small cortical metastases are potential candidates for outpatient consideration, said Lakomkin.

"Neuro-oncology is an interesting field for this due to its incredible heterogeneity.

"People may think of really complex operations, but a lot are simpler. It is [important] to look at whether there is a subset of these patients who can benefit from the procedures," he added.

For the study, investigators evaluated data on 3671 adult patients in a prospective, multicenter surgical registry obtained from the American College of Surgeons. All the patients in the study underwent craniotomy for resection of meningioma with low- or high-grade glioma.

Of the participants, 148 (4%) had outpatient surgery. Patients with skull base tumors, including acoustic neuromas, were excluded from the study.

As expected and likely indicative of the selection bias of less risky tumors treated in the day surgery setting, mortality rates were significantly lower for outpatients than for inpatients, at 0.7% vs 3.3%. Outpatients also had fewer major complications (1.2% vs 16.6%) and minor complications (4.7% vs 8.6%).

After adjusting for comorbidities, smoking status, operative time, and age, the between-group differences lost statistical significance. Still, outpatient procedures were not significantly linked to increased mortality (odds ratio [OR], 0.83; 95% CI, 0.78 – 0.88; P = 0.89) or AEs (OR, 0.49; 95% CI, 0.15 – 1.56; P = .221).

In quantifying patient comorbidity burden, the investigators found that modified Charlson Comorbidity Index (CCI) score was significantly associated with mortality (OR, 1.21; P < .001), major complications (OR, 1.04; P = 04), and minor complications (OR, 1.12; P < .001).

On receiver operating curve analysis, a CCI score of 3 was determined to be the ideal cutoff for maximized sensitivity and specificity for all three metrics of mortality and complications.

"These data demonstrate that a specific cutoff of 3 in the CCI had utility in identifying the group associated with an increased risk for adverse events. This may serve as a starting point for additional studies describing the characteristics and outcomes of neurosurgical patients being treated at ambulatory surgery centers," Lakomkin said.

Ultimately, "comorbidity burden is the primary predictor of suboptimal postoperative outcomes," he added.

Study limitations include the fact that significant variables, such as the location of gliomas or meningiomas, couldn't be determined.

"This is key because it really impacts the surgical approach and the consequent risk of adverse events," Lakomkin said.

In addition, the investigators were only able to document AEs that occurred within 30 days of surgery, so they were unable to determine potential complications that occurred after this time point.

Future studies should "identify the tumor characteristics, including size, type, location, [and] depth from the surface, as well as the comorbidity burden that would maximize the probability of achieving an outstanding outcome at an ambulatory surgical center," he said.

Favorable Argument

Commenting on the study for Medscape Medical News, Rohan Ramakrishna, MD, Department of Neurological Surgery, Weill Cornell Medical Center, New York–Presbyterian Hospital, New York City, noted that the potential for reducing COVID-19 exposure is "absolutely" an argument in favor of outpatient procedures for brain surgeries, when possible.

The pandemic is propelling more careful assessment of the types of procedures that can be performed on an outpatient basis, said Ramakrishna, who was not involved with the research.

"Outpatient brain tumor surgery should be encouraged when possible. This study draws attention to the fact that these surgeries can be done safely in carefully selected patients," he said.

However, he emphasized that group size is relatively small in neurosurgical oncology, as shown in the abstract, where only 4% of pooled cases involved outpatient surgeries.

The consideration of COVID-19 in outpatient vs inpatient neuro-oncology decisions was addressed in a topic review published online April 9 in the Journal of Neuro-Oncology by Ramakrishna and colleagues and the AANS/CNS Tumor Section and Society for Neuro-Oncology. It provides guidance for neuro-oncology practitioners on these issues.

The best way to manage the backlog of semiurgent cases due to COVID-19 "is to thoughtfully consider when and how neuro-oncology care (both interventional and outpatient) must be delivered, while simultaneously considering both risks to patients/staff and burden on health care systems," they note.

Lakomkin and Ramakrishna have reported no relevant financial relationships.

American Association of Neurological Surgeons (AANS) 2020 Annual Meeting: Abstract 206.

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