HCA International Foundation Travelling Scholarship REPORT

Andrew F. Alalade MBBS, MRCS, FEBNS, FRCS (SN)
Department of Neurological Surgery
Weill Cornell Medical Center/New York Presbyterian hospital
New York, United States.
Duration: January 2017 – June 2017

The New York Presbyterian Hospital-Weill Cornell Medical Center (WCMC) has been consistently ranked as the first in the New York City Metropolitan area, and one of the best in the United States.  I was privileged to be selected for the Minimally Invasive Endoscopic Brain and Skull Base fellowship with supervision by Dr Theodore Schwartz. Dr Schwartz is the David and Ursel Barnes Professor in Minimally Invasive Surgery at the institution, and is widely known for his work in minimally invasive endoscopy and pituitary surgery. The CSF leak rates following his endonasal endoscopic procedures are among the best quoted in the literature, so I was very keen to learn the nuances and techniques utilised during the surgeries. Dr Schwartz works closely with Dr Vijay Anand, an ENT/Endoscopic sinus surgeon and former president of the American Rhinologic Society.

My fellowship stint lasted from January to June 2017, working alongside other members of the neurosurgical team. There was also the Skull Base Innovation laboratory where skull base cadaveric dissections were done. This allowed me to spend some time studying and understanding the anatomy of the skull base (endoscopic and open) in a more detailed manner. Mondays, Wednesdays and Thursdays were usually spent in the operating room (O.R) while Tuesdays and Fridays were spent in the clinic. The week usually started off with a 7am M&M meeting on Monday where the residents presented cases from the preceding week. This was then followed by a Clinical governance meeting, where speakers were invited from all over the United States. During the week, there were also the Pituitary, Tumour and Epilepsy Board multidisciplinary meetings where interesting cases were reviewed and discussed. There was a great research drive, with several projects going on in the various sub-units of the neurosurgical department i.e. clinical department, skull base innovations laboratory and the research laboratory. Multiple clinical trials were also being carried out in the hospital.  I got involved in interesting skull base-themed projects, and published several papers and a book chapter.

The time at WCMC enabled me to learn a lot about endoscopic neurosurgery, especially regarding the endonasal skull base approaches. Tumours like pituitary adenomas, meningiomas, craniopharyngiomas, angiofibromas, Rathke’s cleft cysts, epidermoid tumours, chondrosarcomas etc where resected endoscopically with good outcomes. It was interesting to see the Neurosurgery-ENT collaborations during these cases. The pre-operative preparation, operative set-up, use of neuronavigation, utilisation of intrathecal fluorescein, techniques in raising a nasoseptal flap, gasket seal technique (using fascia lata and Medpor) etc were closely monitored by myself. I was able to appreciate the surgical indications for the transplanum, transethmoidal, transmaxillary, transclival, transpterygoid approaches and the supraorbital craniotomies for olfactory groove meningiomas (through an eyebrow incision). I also saw a couple of endoscopic endonasal odontoidectomy procedures for ventral brainstem compression in pediatric patients with Chiari malformations.

About 3 months into my fellowship, I travelled to New Orleans for the 27th North American Skull Base Society (NASBS) Meeting. The theme of the meeting was “Mastery and Legacy in Skull base Surgery: Lessons in Synchronicity”. The main highlight of the meeting was the Albert Rhoton memorial. Albert Rhoton Jr was a brilliant neurosurgeon who revolutionised neurosurgical approaches with his pioneering work in Neuroanatomy. He was the author of one the most popular neurosurgical texts.  It was heart-warming listening to testimonials from many of the neurosurgeons he trained, as they all spoke highly of him during their presentations.  Personally, the other stand-out highlights for me were meeting familiar faces like Prof. Michael Gleeson, Prof. Alan Crockard and Mr Robert Bradford from the UK and Dr Adeleye from Nigeria. I gave 2 presentations from some of the work I did as a registrar at The National Hospital for Neurology and Neurosurgery (Queen Square), London. The feedback I received was enlightening, and I plan to submit some work for the 2018 meeting too.

As part of my fellowship, I also got to attend the “Advanced Endoscopic Skull Base and Pituitary Surgery 2017 course” in May 2017 alongside about 30 other skull base surgeons from all over the world. Dr Schwartz and Dr Anand were the course directors, and they oversaw the comprehensive 2-day course which combined didactic sessions on endoscopic skull base surgical techniques and treatment of related pathological conditions with cadaveric dissection workshops. This course helped me to understand a lot about endoscopic skull base approaches.

My experience at the Weill Cornell Medical Center helped to improve my skull base knowledge and expertise, and made me realise how a well-run skull base team can significantly improve a patient’s healthcare experience. Discussions with patients should always involve all possible options, with an elaborate explanation of the associated pros and cons. It was an absolute honour to experience the skull base practice in this centre of excellence, and I am confident that the knowledge and skills gained will help shape my own clinical practice. Combining busy clinical duties with academic/research work was quite inspiring, and it definitely changed my perspective and gave me brilliant ideas to work on. I am grateful to Dr Theodore Schwartz, Dr Jeffrey Greenfield, Dr Vijay Anand and Dr Antonio Bernardo at the Weill Cornell Medical Center for the learning opportunities during my fellowship. I will also like to express my gratitude to the HCA International Foundation for accepting my application and for providing the Travelling Scholarship, which definitely helped during my time in New York.