Reconfiguration from emergency to urgent elective neurosurgery for glioblastoma patients improves length of stay, surgical adjunct use, and extent of resective surgery

Abstract

Background Glioblastoma (GB) is the most common intrinsic brain cancer and notorious for its aggressive nature. Despite widespread research and optimization of clinical management, the improvement in overall survival has been limited. The aim of this study was to characterise the impact of service reconfiguration on GB outcomes in a single centre. Methods Patients with a histopathological confirmation of diagnosis of GB between 01/01/2014 and 31/12/2019 were retrospectively identified. Demographic and tumour characteristics, survival, treatment (surgical and oncological), admission status, use of surgical adjunct (5-aminolevulinic acid, intra-operative neuro-monitoring), length of stay, extent of resection, and surgical complications were recorded from the hospital databases. Results From August 2018 the neurosurgical oncology service was reconfigured to manage high grade tumours on an urgent outpatient basis by surgeons specialising in oncology. We demonstrate that these changes resulted in an increase of elective admissions, greater use of intra-operative adjuncts resulting in improved extent of tumour resection, and reduction in median length of stay and associated cost-savings. Conclusions Optimising neuro-oncology patient management through service reconfiguration resulted in increased use of intra-operative adjuncts, improved surgical outcomes, and reduced hospital costs. These changes also have the potential to improve survival and disease-free progression for patients with GB.

Temporal trends in neurosurgical volume and length of stay in a public healthcare system: A decade in review with a focus on the COVID-19 pandemic

“…Results from an earlier study support this trend, which has been directly linked to a reduction in hospital burden and patient satisfaction and is undoubtedly a great success within the field of neurosurgery over the last decade. [23] With regard to trends between LOS and differing age groups, "Spinal, " "Functional, " "CSF, " and "Neuro-oncology" subspecialties had a statistically significant increase in median LOS with age, while "Skull base" showed the opposite trend. Our results for "Neuro-oncology" contradict an earlier study showing a negative correlation between the age of patients presenting with a tumor and the hospital LOS.…”

“…Results from an earlier study support this trend, which has been directly linked to a reduction in hospital burden and patient satisfaction and is undoubtedly a great success within the field of neurosurgery over the last decade. [ 23 ]…”

Neuro-oncologic Emergencies

“…Outcomes are better if surgery can be performed electively as opposed to emergently. 39 Additionally, early transition to radiosurgery to accelerate adjuvant therapy appears promising and safe. 109 Impaired wound healing and infection and perioperative hemorrhagic complications are more common in patients with long-term exposure to corticosteroids and in those with recent exposure to antiangiogenic agents (eg, bevacizumab).…”

“…Endoscopic third ventriculostomy or concurrent CSF diversion, either temporary through external ventricular drain placement or as a bridge to ventriculoperitoneal shunt, is often used in the presence of CSF flow obstruction, particularly in patients with infratentorial tumors 14 . Planned surgeries (ie, urgent elective versus emergent) in the setting of neurologic emergencies should occur with optimal use of surgical adjuncts (eg, intraoperative neuronavigation, fluorescence-guided resection, cortical mapping) 12 because those procedures may be more likely to achieve the best longitudinal outcomes 39 given the direct association of maximal tumor resection with symptom control and progression-free and overall survival. Postoperative imaging with MRI should be performed within 48 hours from resection in patients who are clinically able to tolerate lying flat to determine the extent of resection 12 .…”

“…Perisurgical morbidity of ventriculoperitoneal shunt placement is slightly higher in patients with CNS malignancy, with rates of complications at 4% to 10%; peritoneal seeding of tumor has not been demonstrated. Outcomes are better if surgery can be performed electively as opposed to emergently 39 . Additionally, early transition to radiosurgery to accelerate adjuvant therapy appears promising and safe 109 .…”